Provider Demographics
NPI:1538169792
Name:OSULLIVAN, TIM B (NP)
Entity type:Individual
Prefix:
First Name:TIM
Middle Name:B
Last Name:OSULLIVAN
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4444 GREGORY DR
Mailing Address - Street 2:
Mailing Address - City:MAUMEE
Mailing Address - State:OH
Mailing Address - Zip Code:43537-1822
Mailing Address - Country:US
Mailing Address - Phone:419-893-7906
Mailing Address - Fax:
Practice Address - Street 1:4444 GREGORY DR
Practice Address - Street 2:
Practice Address - City:MAUMEE
Practice Address - State:OH
Practice Address - Zip Code:43537-1822
Practice Address - Country:US
Practice Address - Phone:419-893-7606
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2019-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH154376163W00000X
OHRN154376163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHP00186819OtherRRMC
OH000000379377OtherANTHEM
OH2346634Medicaid
OH000000379377OtherANTHEM
OH2346634Medicaid
OH2346634Medicaid