Healthcare Provider Details

I. General information

NPI: 1770552457
Provider Name (Legal Business Name): THOMAS MORGAN SULLIVAN ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BUFFALO GROVE HIGH SCHOOL 1100 W. DUNDEE RD.
BUFFALO GROVE IL
60089
US

IV. Provider business mailing address

345 ALABAMA TRL
CAROL STREAM IL
60188-1374
US

V. Phone/Fax

Practice location:
  • Phone: 847-718-4177
  • Fax: 847-718-4178
Mailing address:
  • Phone: 630-407-0279
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: