MEDICARE: TIMOTHY MICHAEL SULLIVAN MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2086S0129X	Vascular Surgery Physician	44841	MN
2	2085R0204X	Vascular & Interventional Radiology Physician	44841	MN
3	2086S0129X	Vascular Surgery Physician	5847	SD
4	2085R0204X	Vascular & Interventional Radiology Physician	5847	SD

General Provider Information

NPI Number	:	1063484061
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TIMOTHY MICHAEL SULLIVAN MD

Provider Business Mailing Address
First Line	:	2925 CHICAGO AVE
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55407-1321
Country	:	US
Telephone Number	:	612-262-5000
Fax Number	:

Provider Business Practice Location Address
First Line	:	920 E 28TH ST
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55407-1139
Country	:	US
Telephone Number	:	612-863-6800
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/03/2006
Last Update Date	:	11/14/2011

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