MEDICARE: THOMAS C. SULLIVAN, M.D., INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208C00000X	Colon & Rectal Surgery Physician	A41748	CA

General Provider Information

NPI Number	:	1437185717
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THOMAS C. SULLIVAN, M.D., INC.

Provider Business Mailing Address
First Line	:	550 WASHINGTON ST
Second Line	:	SUITE 821
City	:	SAN DIEGO
State	:	CA
Zip	:	92103-2213
Country	:	US
Telephone Number	:	619-686-4011
Fax Number	:	619-686-4041

Provider Business Practice Location Address
First Line	:	550 WASHINGTON ST
Second Line	:	SUITE 821
City	:	SAN DIEGO
State	:	CA
Zip	:	92103-2213
Country	:	US
Telephone Number	:	619-686-4011
Fax Number	:	619-686-4041

Authorized Official
Title or Position	:	PRESIDENT
Name	:	THOMAS C. SULLIVAN
Credential	:	M.D.
Telephone Number	:	619-686-4011

Provider Enumeration Date	:	06/25/2006
Last Update Date	:	08/22/2020

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