MEDICARE: KEITH JOSEPH SULLIVAN PT

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	225100000X	Physical Therapist	4415	MN

General Provider Information

NPI Number	:	1811957889
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEITH JOSEPH SULLIVAN PT

Provider Business Mailing Address
First Line	:	7581 9TH ST N STE 100
Second Line	:
City	:	OAKDALE
State	:	MN
Zip	:	55128-6635
Country	:	US
Telephone Number	:	651-748-4338
Fax Number	:

Provider Business Practice Location Address
First Line	:	2800 CHICAGO AVE STE 200
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55407-1353
Country	:	US
Telephone Number	:	612-872-2700
Fax Number	:

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

Provider Enumeration Date	:	03/24/2006
Last Update Date	:	09/24/2019

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