Basic Information
| Provider Information | |||||||||
| NPI: | 1134112774 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SULLIVAN | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | JOSEPH | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1020 LAKE SUMTER LNDG | ||||||||
| Address2: | |||||||||
| City: | THE VILLAGES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321622699 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3526748700 | ||||||||
| FaxNumber: | 3526748714 | ||||||||
| Practice Location | |||||||||
| Address1: | 1400 N US HIGHWAY 441 | ||||||||
| Address2: | SUITE 810 | ||||||||
| City: | THE VILLAGES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321598975 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3526748700 | ||||||||
| FaxNumber: | 3526748714 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2005 | ||||||||
| LastUpdateDate: | 11/20/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 173877 | NY | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207X00000X | ME122199 | FL | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 01068506 | 05 | NY | MEDICAID |