Healthcare Provider Details

I. General information

NPI: 1104872001
Provider Name (Legal Business Name): THOMAS DENNIS SULLIVAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2006
Last Update Date: 12/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3795 MANSELL RD
ALPHARETTA GA
30022-8247
US

IV. Provider business mailing address

5318 TROWBRIDGE DR
ATLANTA GA
30338-3623
US

V. Phone/Fax

Practice location:
  • Phone: 404-785-8540
  • Fax: 404-785-8574
Mailing address:
  • Phone: 770-671-8349
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number15512
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: