Provider Demographics
NPI:1124268297
Name:DONALD J SULLIVAN MD
Entity type:Organization
Organization Name:DONALD J SULLIVAN MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:J
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:901-213-5460
Mailing Address - Street 1:PO BOX 1000 DEPT 0194
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38148-0194
Mailing Address - Country:US
Mailing Address - Phone:901-315-7932
Mailing Address - Fax:
Practice Address - Street 1:9636 FOX HILL CIR N
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38139-6810
Practice Address - Country:US
Practice Address - Phone:901-315-7932
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-02
Last Update Date:2024-04-09
Deactivation Date:2009-05-04
Deactivation Code:
Reactivation Date:2011-03-03
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1522858Medicaid