Healthcare Provider Details

I. General information

NPI: 1508895988
Provider Name (Legal Business Name): THOMAS C. SULLIVAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2006
Last Update Date: 02/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 CRESTWOOD CIR SUITE L
MENA AR
71953-5511
US

IV. Provider business mailing address

311 MORROW ST N
MENA AR
71953-2516
US

V. Phone/Fax

Practice location:
  • Phone: 479-394-1414
  • Fax: 479-394-2612
Mailing address:
  • Phone: 479-394-6100
  • Fax: 479-394-4577

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License NumberA41748
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: