Provider Demographics
NPI:1871630111
Name:SULLIVAN, THOMAS E (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:E
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 1:6 BRACKENBURY LN
Mailing Address - Street 2:
Mailing Address - City:BEVERLY
Mailing Address - State:MA
Mailing Address - Zip Code:01915-3822
Mailing Address - Country:US
Mailing Address - Phone:978-927-6477
Mailing Address - Fax:
Practice Address - Street 1:6 BRACKENBURY LN
Practice Address - Street 2:
Practice Address - City:BEVERLY
Practice Address - State:MA
Practice Address - Zip Code:01915-3822
Practice Address - Country:US
Practice Address - Phone:978-927-6477
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2012-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA34941207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAB75259Medicare UPIN
MAK08269Medicare PIN