Basic Information
| Provider Information | |||||||||
| NPI: | 1992817126 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SULLIVAN | ||||||||
| FirstName: | MARTIN | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1869 | ||||||||
| Address2: | |||||||||
| City: | FLETCHER | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287321869 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8286875616 | ||||||||
| FaxNumber: | 8286508076 | ||||||||
| Practice Location | |||||||||
| Address1: | 50 HOSPITAL DR | ||||||||
| Address2: | SUITE 3B2 | ||||||||
| City: | HENDERSONVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287925248 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8286870088 | ||||||||
| FaxNumber: | 8286846693 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/01/2006 | ||||||||
| LastUpdateDate: | 04/01/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 45065 | TN | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RC0000X | 2003000087 | MO | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RC0000X | 29044 | NC | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 1514006 | 05 | TN | MEDICAID | 203715016 | 05 | MO | MEDICAID | 4230692 | 01 | TN | BCBST | OTHER | 10001627200 | 01 | MO | COMMUNITY HEALTH PLAN | OTHER |