Provider Demographics
NPI:1326024068
Name:SULLIVAN, THOMAS (PT)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 TROY SCHENECTADY RD
Mailing Address - Street 2:SUITE 209
Mailing Address - City:LATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12110-2442
Mailing Address - Country:US
Mailing Address - Phone:518-786-1667
Mailing Address - Fax:518-786-1954
Practice Address - Street 1:244 ONTARIO ST
Practice Address - Street 2:
Practice Address - City:COHOES
Practice Address - State:NY
Practice Address - Zip Code:12047-2868
Practice Address - Country:US
Practice Address - Phone:518-235-3358
Practice Address - Fax:518-235-2823
Is Sole Proprietor?:No
Enumeration Date:2005-12-15
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022964-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP00467117OtherRAILROAD MEDICARE
NYCC7200Medicare PIN