Basic Information
| Provider Information | |||||||||
| NPI: | 1295742419 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SULLIVAN | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5440 CHANDLEY FARM CIR | ||||||||
| Address2: | |||||||||
| City: | CENTREVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 201201239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7038151124 | ||||||||
| FaxNumber: | 7038157411 | ||||||||
| Practice Location | |||||||||
| Address1: | 12018 SUNRISE VALLEY DR | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | RESTON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 201913432 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5712625200 | ||||||||
| FaxNumber: | 5715217249 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2006 | ||||||||
| LastUpdateDate: | 03/21/2011 | ||||||||
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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 | 207Q00000X | 0101043001 | VA | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207QH0002X | 0101043001 | VA | N | Allopathic & Osteopathic Physicians | Family Medicine | Hospice and Palliative Medicine |
ID Information
| ID | Type | State | Issuer | Description | 010051185 | 05 | VA | MEDICAID |