Provider Demographics
NPI:1992817126
Name:SULLIVAN, MARTIN J (MD)
Entity type:Individual
Prefix:
First Name:MARTIN
Middle Name:J
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1869
Mailing Address - Street 2:
Mailing Address - City:FLETCHER
Mailing Address - State:NC
Mailing Address - Zip Code:28732-1869
Mailing Address - Country:US
Mailing Address - Phone:828-687-5616
Mailing Address - Fax:828-650-8076
Practice Address - Street 1:50 HOSPITAL DR
Practice Address - Street 2:SUITE 3B2
Practice Address - City:HENDERSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28792-5248
Practice Address - Country:US
Practice Address - Phone:828-687-0088
Practice Address - Fax:828-684-6693
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2021-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN45065207RC0000X
MO2003000087207RC0000X
NC29044207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1514006Medicaid
MO203715016Medicaid
TN4230692OtherBCBST
MO10001627200OtherCOMMUNITY HEALTH PLAN
TN1514006Medicaid
TN4230692OtherBCBST
MO10001627200OtherCOMMUNITY HEALTH PLAN