Provider Demographics
NPI:1003982711
Name:SULLIVAN, TODD MICHAEL (MPT)
Entity Type:Individual
Prefix:MR
First Name:TODD
Middle Name:MICHAEL
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4251 LAHMEYER RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46815-5676
Mailing Address - Country:US
Mailing Address - Phone:260-432-4700
Mailing Address - Fax:260-459-9262
Practice Address - Street 1:7930 W JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-4140
Practice Address - Country:US
Practice Address - Phone:260-432-5800
Practice Address - Fax:260-432-9555
Is Sole Proprietor?:No
Enumeration Date:2006-11-27
Last Update Date:2010-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05008436A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000340405OtherANTHEM BCBS
IN200349570AMedicaid
INN282359OtherHARMONY
IN1424OtherPHP
IN4423623OtherAETNA
IN35179001202OtherCARESOURCE
IN200349570AMedicaid