Provider Demographics
NPI:1679914683
Name:SULLIVAN FAMILY PRACTICE, INC.
Entity type:Organization
Organization Name:SULLIVAN FAMILY PRACTICE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:W
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:615-299-5341
Mailing Address - Street 1:3511 OLD CLARKSVILLE PIKE
Mailing Address - Street 2:
Mailing Address - City:JOELTON
Mailing Address - State:TN
Mailing Address - Zip Code:37080-8892
Mailing Address - Country:US
Mailing Address - Phone:615-299-5341
Mailing Address - Fax:
Practice Address - Street 1:3511 OLD CLARKSVILLE PIKE
Practice Address - Street 2:
Practice Address - City:JOELTON
Practice Address - State:TN
Practice Address - Zip Code:37080-8892
Practice Address - Country:US
Practice Address - Phone:615-299-5341
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-08
Last Update Date:2013-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty