Provider Demographics
NPI:1053379644
Name:SULLIVAN, JEREMY TYSON (MD)
Entity type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:TYSON
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10601 WINTERWOOD
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46032-8258
Mailing Address - Country:US
Mailing Address - Phone:615-478-3720
Mailing Address - Fax:
Practice Address - Street 1:10601 WINTERWOOD
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-8258
Practice Address - Country:US
Practice Address - Phone:615-478-3720
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-03
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN35131174400000X
IN01066525A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3865060Medicaid
BS7284021OtherFEDERAL DEA NUMBER
TN3865060Medicaid
BS7284021OtherFEDERAL DEA NUMBER