Basic Information
| Provider Information | |||||||||
| NPI: | 1124268297 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DONALD J SULLIVAN MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1000 DEPT 0194 | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381480194 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9012135460 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4100 AUSTIN PEAY HWY | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381282502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9012135460 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/02/2009 | ||||||||
| LastUpdateDate: | 03/21/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 05/04/2009 | ||||||||
| NPIReactivationDate: | 03/03/2011 | ||||||||
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| AuthorizedOfficialLastName: | SULLIVAN | ||||||||
| AuthorizedOfficialFirstName: | DONALD | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | AUTHORIZED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 9012135460 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208VP0000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1522858 | 05 | TN | MEDICAID |