Provider Demographics
NPI:1366451742
Name:THOMAS D. SULLIVAN, MD, SC
Entity Type:Organization
Organization Name:THOMAS D. SULLIVAN, MD, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:D
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:630-574-0934
Mailing Address - Street 1:PO BOX 3575
Mailing Address - Street 2:
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60522-3575
Mailing Address - Country:US
Mailing Address - Phone:630-574-0934
Mailing Address - Fax:630-574-0934
Practice Address - Street 1:120 N OAK ST
Practice Address - Street 2:NEUROPHYSIOLOGY DEPARTMENT
Practice Address - City:HINSDALE
Practice Address - State:IL
Practice Address - Zip Code:60521-3829
Practice Address - Country:US
Practice Address - Phone:630-574-0934
Practice Address - Fax:630-574-0934
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-05
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-043333174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036-043333Medicaid
IL02201078OtherBLUE SHIELD
IL213823Medicare PIN
ILD10183Medicare UPIN