Healthcare Provider Details

I. General information

NPI: 1992817126
Provider Name (Legal Business Name): MARTIN J SULLIVAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2006
Last Update Date: 04/01/2021
Certification Date: 04/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 HOSPITAL DR SUITE 3B2
HENDERSONVILLE NC
28792-5248
US

IV. Provider business mailing address

PO BOX 1869
FLETCHER NC
28732-1869
US

V. Phone/Fax

Practice location:
  • Phone: 828-687-0088
  • Fax: 828-684-6693
Mailing address:
  • Phone: 828-687-5616
  • Fax: 828-650-8076

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number45065
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number2003000087
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number29044
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: