Healthcare Provider Details

I. General information

NPI: 1376637215
Provider Name (Legal Business Name): KENNETH W SULLIVAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 06/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3511 OLD CLARKSVILLE PIKE
JOELTON TN
37080-8892
US

IV. Provider business mailing address

PO BOX 57
SPRINGFIELD TN
37172-0057
US

V. Phone/Fax

Practice location:
  • Phone: 615-299-5341
  • Fax: 615-299-5386
Mailing address:
  • Phone: 615-299-5341
  • Fax: 615-299-5386

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number27509
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: