MEDICARE: SPENCER K SULLIVAN MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2080P0207X	Pediatric Hematology & Oncology Physician	23304	MS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1073735114
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SPENCER K SULLIVAN MD

Provider Business Mailing Address
First Line	:	7731 OLD CANTON RD STE B
Second Line	:
City	:	MADISON
State	:	MS
Zip	:	39110-6115
Country	:	US
Telephone Number	:	601-499-0935
Fax Number	:	601-499-0936

Provider Business Practice Location Address
First Line	:	7730 OLD CANTON RD BLDG B
Second Line	:
City	:	MADISON
State	:	MS
Zip	:	39110-9299
Country	:	US
Telephone Number	:	601-499-0935
Fax Number	:	601-499-0936

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/02/2007
Last Update Date	:	04/14/2025

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