Provider Demographics
NPI:1417085606
Name:SULLIVAN, RYAN RICHARD (MD)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:RICHARD
Last Name:SULLIVAN
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 1:100 BLYTHEWOOD DR STE A
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:TN
Mailing Address - Zip Code:38401-4828
Mailing Address - Country:US
Mailing Address - Phone:615-302-5000
Mailing Address - Fax:615-302-5006
Practice Address - Street 1:1229 RESERVE BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:SPRING HILL
Practice Address - State:TN
Practice Address - Zip Code:37174
Practice Address - Country:US
Practice Address - Phone:615-302-5000
Practice Address - Fax:615-302-5006
Is Sole Proprietor?:No
Enumeration Date:2007-03-01
Last Update Date:2018-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN38819207KA0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3001046Medicare PIN