Provider Demographics
NPI:1831381979
Name:SULLIVAN, TAMMY SUE (DC)
Entity type:Individual
Prefix:DR
First Name:TAMMY
Middle Name:SUE
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:DC
Other - Prefix:DR
Other - First Name:TAMMY
Other - Middle Name:SUE
Other - Last Name:EDINGTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:PO BOX 275
Mailing Address - Street 2:
Mailing Address - City:PERRY
Mailing Address - State:MI
Mailing Address - Zip Code:48872-0275
Mailing Address - Country:US
Mailing Address - Phone:517-625-0577
Mailing Address - Fax:517-625-0578
Practice Address - Street 1:245 N MAIN ST
Practice Address - Street 2:
Practice Address - City:PERRY
Practice Address - State:MI
Practice Address - Zip Code:48872-0275
Practice Address - Country:US
Practice Address - Phone:517-625-0577
Practice Address - Fax:517-625-0578
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-13
Last Update Date:2009-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301007998111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIU863-12Medicare UPIN