1992817126 NPI number — MARTIN J SULLIVAN MD

Table of content: MARTIN J SULLIVAN MD (NPI 1992817126)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992817126 NPI number — MARTIN J SULLIVAN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SULLIVAN
Provider First Name:
MARTIN
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1992817126
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/01/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1869
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FLETCHER
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28732-1869
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
828-687-5616
Provider Business Mailing Address Fax Number:
828-650-8076

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
50 HOSPITAL DR
Provider Second Line Business Practice Location Address:
SUITE 3B2
Provider Business Practice Location Address City Name:
HENDERSONVILLE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28792-5248
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
828-687-0088
Provider Business Practice Location Address Fax Number:
828-684-6693
Provider Enumeration Date:
09/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RC0000X , with the licence number:  45065 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RC0000X , with the licence number: 2003000087 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RC0000X , with the licence number: 29044 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1514006 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 203715016 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4230692 . This is a "BCBST" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 10001627200 . This is a "COMMUNITY HEALTH PLAN" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".




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