Healthcare Provider Details

I. General information

NPI: 1073735114
Provider Name (Legal Business Name): SPENCER K SULLIVAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2007
Last Update Date: 04/14/2025
Certification Date: 04/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7730 OLD CANTON RD BLDG B
MADISON MS
39110-9299
US

IV. Provider business mailing address

7731 OLD CANTON RD STE B
MADISON MS
39110-6115
US

V. Phone/Fax

Practice location:
  • Phone: 601-499-0935
  • Fax: 601-499-0936
Mailing address:
  • Phone: 601-499-0935
  • Fax: 601-499-0936

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0207X
TaxonomyPediatric Hematology & Oncology Physician
License Number23304
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: