Healthcare Provider Details

I. General information

NPI: 1487651311
Provider Name (Legal Business Name): THOMAS ALLEN SULT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2005
Last Update Date: 11/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7900 CHAPIN DR NE
NEW LONDON MN
56273-8538
US

IV. Provider business mailing address

PO BOX 607
NEW LONDON MN
56273-0607
US

V. Phone/Fax

Practice location:
  • Phone: 320-347-1212
  • Fax: 320-347-1200
Mailing address:
  • Phone: 320-347-1212
  • Fax: 320-347-1200

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number37054
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: