Healthcare Provider Details

I. General information

NPI: 1679914683
Provider Name (Legal Business Name): SULLIVAN FAMILY PRACTICE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2013
Last Update Date: 07/08/2013
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

3511 OLD CLARKSVILLE PIKE
JOELTON TN
37080-8892
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. KENNETH W SULLIVAN
Title or Position: OWNER
Credential: M.D.
Phone: 615-299-5341