Basic Information
| Provider Information | |||||||||
| NPI: | 1538368923 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SULLIVAN | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 945395 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303945395 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8888209533 | ||||||||
| FaxNumber: | 9198739821 | ||||||||
| Practice Location | |||||||||
| Address1: | 1025 MOREHEAD MEDICAL DR | ||||||||
| Address2: | SUITE 225 | ||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282042963 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043775772 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/16/2007 | ||||||||
| LastUpdateDate: | 10/07/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 2008-01579 | NC | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | 32237 | SC | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | 19223 | MS | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207LP2900X | 32237 | SC | N | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 208VP0014X | 32237 | SC | N | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine | 208VP0014X | 2008-01579 | NC | N | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine | 207LP2900X | 2008-01579 | NC | Y | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 5911895 | 05 | NC | MEDICAID | 152J3 | 01 | NC | BCBSNC | OTHER | P01011085 | 01 | NC | RAILROAD-MEDICARE | OTHER | NC1040 | 05 | SC | MEDICAID | P01163110 | 01 | SC | RAILROAD-MEDICARE | OTHER |