Provider Demographics
NPI:1356346605
Name:SMITH, SULLIVAN K (MD)
Entity type:Individual
Prefix:DR
First Name:SULLIVAN
Middle Name:K
Last Name:SMITH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 MEDICAL CENTER BLVD
Mailing Address - Street 2:PO BOX 938
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38501-4294
Mailing Address - Country:US
Mailing Address - Phone:931-783-2334
Mailing Address - Fax:931-783-2253
Practice Address - Street 1:1 MEDICAL CENTER BLVD
Practice Address - Street 2:
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38501-4294
Practice Address - Country:US
Practice Address - Phone:931-783-2334
Practice Address - Fax:931-783-2253
Is Sole Proprietor?:No
Enumeration Date:2005-06-14
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN18081207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3100062Medicaid
TNBS0941345OtherDEA CERTIFICATE
TN3028729Medicare ID - Type UnspecifiedVMG MEDICARE
A99265Medicare UPIN