Provider Demographics
NPI:1114004181
Name:SULLIVAN, THOMAS ANDREW (MD)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:ANDREW
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 1:2223 LIME KILN RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54311-6213
Mailing Address - Country:US
Mailing Address - Phone:920-430-8120
Mailing Address - Fax:920-430-8122
Practice Address - Street 1:2223 LIME KILN RD
Practice Address - Street 2:SUITE 1
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54311-6213
Practice Address - Country:US
Practice Address - Phone:920-430-8120
Practice Address - Fax:920-430-8122
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2010-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI44603207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34213200Medicaid
WI6206770001Medicare NSC
G82767Medicare UPIN
WI34213200Medicaid