Provider Demographics
NPI:1851852560
Name:SMITH, SULLIVAN MCINTOSH (MD)
Entity Type:Individual
Prefix:
First Name:SULLIVAN
Middle Name:MCINTOSH
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 1:2 HARMONY HILL RD
Mailing Address - Street 2:
Mailing Address - City:DUXBURY
Mailing Address - State:MA
Mailing Address - Zip Code:02332-3882
Mailing Address - Country:US
Mailing Address - Phone:781-635-5061
Mailing Address - Fax:
Practice Address - Street 1:2160 S 1ST AVE
Practice Address - Street 2:
Practice Address - City:MAYWOOD
Practice Address - State:IL
Practice Address - Zip Code:60153-3328
Practice Address - Country:US
Practice Address - Phone:781-635-5061
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-26
Last Update Date:2019-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL125.074394207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program