MEDICARE: DR. THOMAS E. SULLIVAN PH.D.

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	103G00000X	Clinical Neuropsychologist	5083	OH
2	103T00000X	Psychologist	5083	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	257968	OTHER	OH	VALUE OPTIONS PROVIDER ID
2	000000066833	OTHER	OH	ANTHEM ID#
3	A294802	OTHER	OH	VALUE OPTIONS VIN

General Provider Information

NPI Number	:	1316912421
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. THOMAS E. SULLIVAN PH.D.

Provider Business Mailing Address
First Line	:	2810 MACK RD
Second Line	:
City	:	FAIRFIELD
State	:	OH
Zip	:	45014-5130
Country	:	US
Telephone Number	:	513-874-4530
Fax Number	:	513-346-3811

Provider Business Practice Location Address
First Line	:	2810 MACK RD
Second Line	:
City	:	FAIRFIELD
State	:	OH
Zip	:	45014-5130
Country	:	US
Telephone Number	:	513-874-4530
Fax Number	:	513-346-3811

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

Provider Enumeration Date	:	02/22/2006
Last Update Date	:	09/11/2025

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