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NPI Code Detail

MEDICARE: SULLIVAN FAMILY PRACTICE, LLC

MEDICARE: SULLIVAN FAMILY PRACTICE, LLC
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
1261QR1300XRural Health Clinic/Center01036108IN
2207Q00000XFamily Medicine Physician01036108IN

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1153868OTHERINRURAL HEALTH CLINIC
2MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1770502981
Entity Type Code : Organization
Provider Name (Legal Business Name) : SULLIVAN FAMILY PRACTICE, LLC
Provider Business Mailing Address
First Line : 2229 MARY SHERMAN DR
Second Line : PO BOX 230
City : SULLIVAN
State : IN
Zip : 47882-7633
Country : US
Telephone Number : 812-268-3318
Fax Number : 812-268-4017
Provider Business Practice Location Address
First Line : 2229 MARY SHERMAN DR
Second Line :
City : SULLIVAN
State : IN
Zip : 47882-7633
Country : US
Telephone Number : 812-268-3318
Fax Number : 812-268-4017
Authorized Official
Title or Position : ADMINISTRATOR
Name : MRS. SUSAN LYNN HELMAN
Credential :
Telephone Number : 812-268-3318
Provider Enumeration Date : 07/19/2006
Last Update Date : 10/26/2009

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Directions to “SULLIVAN FAMILY PRACTICE, LLC ” Practice Location

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