Provider Demographics
NPI:1548379233
Name:SULLIVAN, THOMAS S (DC)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:S
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1377 DORCHESTER AVE 2FL
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02122-2950
Mailing Address - Country:US
Mailing Address - Phone:617-822-0900
Mailing Address - Fax:617-822-0800
Practice Address - Street 1:481 FERRY ST
Practice Address - Street 2:
Practice Address - City:MALDEN
Practice Address - State:MA
Practice Address - Zip Code:02148-7851
Practice Address - Country:US
Practice Address - Phone:781-605-0505
Practice Address - Fax:781-605-3458
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA385111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
720367OtherTUFTS
AA61550OtherHARVARD PHC
Y35231OtherBC/BS
11609670OtherCAQH
11609670OtherCAQH
Y35231OtherBC/BS