Provider Demographics
NPI:1396743761
Name:SULLIVAN, HUGH M
Entity type:Individual
Prefix:
First Name:HUGH
Middle Name:M
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:822 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-3718
Mailing Address - Country:US
Mailing Address - Phone:423-246-6251
Mailing Address - Fax:423-246-7230
Practice Address - Street 1:822 BROAD ST
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-3718
Practice Address - Country:US
Practice Address - Phone:423-246-6251
Practice Address - Fax:423-246-7230
Is Sole Proprietor?:No
Enumeration Date:2005-07-11
Last Update Date:2010-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD007907208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3371556Medicaid
B59379Medicare UPIN
TN3371556Medicaid