Basic Information
| Provider Information | |||||||||
| NPI: | 1487203386 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SULLIVAN | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | CARSON BRUYER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 500 CROSS ST | ||||||||
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| City: | BIG STONE CITY | ||||||||
| State: | SD | ||||||||
| PostalCode: | 572168237 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6055411140 | ||||||||
| FaxNumber: | 6055410109 | ||||||||
| Practice Location | |||||||||
| Address1: | 2440 BRIDGE AVE | ||||||||
| Address2: | STE 300 | ||||||||
| City: | ALBERT LEA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 560072098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5075520022 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/04/2019 | ||||||||
| LastUpdateDate: | 03/08/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 11698 | MN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.