Basic Information
| Provider Information | |||||||||
| NPI: | 1750523775 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SULLIVAN | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | CURTIS | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 915 HIGHLAND BLVD | ||||||||
| Address2: | |||||||||
| City: | BOZEMAN | ||||||||
| State: | MT | ||||||||
| PostalCode: | 597156902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4064145000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 334 TOWN CENTER AVE | ||||||||
| Address2: | |||||||||
| City: | BIG SKY | ||||||||
| State: | MT | ||||||||
| PostalCode: | 597151713 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4069956995 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/06/2009 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 14803 | ND | N | Allopathic & Osteopathic Physicians | Family Medicine | 208M00000X | 14803 | ND | N | Allopathic & Osteopathic Physicians | Hospitalist | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207Q00000X | MED-PHYS-LIC-69275 | MT | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1750523775 | 05 | MT | MEDICAID |