Provider Demographics
NPI:1881625424
Name:SULLIVAN, THOMAS D (MD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:D
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: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:630-574-2004
Practice Address - Street 1:120 N. OAK STREET
Practice Address - Street 2:
Practice Address - City:HINSDALE
Practice Address - State:IL
Practice Address - Zip Code:60521
Practice Address - Country:US
Practice Address - Phone:630-856-3901
Practice Address - Fax:630-856-3906
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-05
Last Update Date:2017-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36-2924227174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036-043333Medicaid
IL02201078OtherBLUE SHIELD
IL036-043333Medicaid
IL02201078OtherBLUE SHIELD