Healthcare Provider Details

I. General information

NPI: 1851852560
Provider Name (Legal Business Name): SULLIVAN MCINTOSH SMITH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2019
Last Update Date: 06/24/2025
Certification Date: 06/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

41 MALL RD
BURLINGTON MA
01805-3328
US

IV. Provider business mailing address

PO BOX 24520
NEW YORK NY
10087-3720
US

V. Phone/Fax

Practice location:
  • Phone: 781-744-8000
  • Fax:
Mailing address:
  • Phone: 781-744-8085
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number125.074394
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207YX0007X
TaxonomyPlastic Surgery within the Head & Neck (Otolaryngology) Physician
License Number1021889
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: