Provider Demographics
NPI:1770502981
Name:SULLIVAN FAMILY PRACTICE, LLC
Entity Type:Organization
Organization Name:SULLIVAN FAMILY PRACTICE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:HELMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:812-268-3318
Mailing Address - Street 1:2229 MARY SHERMAN DR
Mailing Address - Street 2:PO BOX 230
Mailing Address - City:SULLIVAN
Mailing Address - State:IN
Mailing Address - Zip Code:47882-7633
Mailing Address - Country:US
Mailing Address - Phone:812-268-3318
Mailing Address - Fax:812-268-4017
Practice Address - Street 1:2229 MARY SHERMAN DR
Practice Address - Street 2:
Practice Address - City:SULLIVAN
Practice Address - State:IN
Practice Address - Zip Code:47882-7633
Practice Address - Country:US
Practice Address - Phone:812-268-3318
Practice Address - Fax:812-268-4017
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-19
Last Update Date:2009-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01036108207Q00000X, 261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN153868OtherRURAL HEALTH CLINIC
IN200015680AMedicaid
IN153868OtherRURAL HEALTH CLINIC
IN153868OtherRURAL HEALTH CLINIC
IN=========OtherTAX ID
IN153868Medicare ID - Type UnspecifiedRURAL HEALTH MEDICARE NUM