Healthcare Provider Details

I. General information

NPI: 1770502981
Provider Name (Legal Business Name): SULLIVAN FAMILY PRACTICE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 10/26/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2229 MARY SHERMAN DR
SULLIVAN IN
47882-7633
US

IV. Provider business mailing address

2229 MARY SHERMAN DR PO BOX 230
SULLIVAN IN
47882-7633
US

V. Phone/Fax

Practice location:
  • Phone: 812-268-3318
  • Fax: 812-268-4017
Mailing address:
  • Phone: 812-268-3318
  • Fax: 812-268-4017

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01036108
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number01036108
License Number StateIN

VIII. Authorized Official

Name: MRS. SUSAN LYNN HELMAN
Title or Position: ADMINISTRATOR
Credential:
Phone: 812-268-3318