Provider Demographics
NPI:1386728483
Name:THOMAS J. SULLIVAN, JR. MD, PA
Entity type:Organization
Organization Name:THOMAS J. SULLIVAN, JR. MD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:J
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:864-225-9566
Mailing Address - Street 1:803 N FANT ST
Mailing Address - Street 2:SUITE 2-C
Mailing Address - City:ANDERSON
Mailing Address - State:SC
Mailing Address - Zip Code:29621-5700
Mailing Address - Country:US
Mailing Address - Phone:864-225-9566
Mailing Address - Fax:864-225-9568
Practice Address - Street 1:803 N FANT ST
Practice Address - Street 2:SUITE 2-C
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29621-5700
Practice Address - Country:US
Practice Address - Phone:864-225-9566
Practice Address - Fax:864-225-9568
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2007-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP4610Medicaid
SCGP4610Medicaid