Basic Information
| Provider Information | |||||||||
| NPI: | 1205263159 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SULLIVAN MEDICAL CLINIC, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6040 W LISBON AVE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532102116 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4144479890 | ||||||||
| FaxNumber: | 4144479891 | ||||||||
| Practice Location | |||||||||
| Address1: | 6040 W LISBON AVE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532102116 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4144479890 | ||||||||
| FaxNumber: | 4144479891 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/07/2013 | ||||||||
| LastUpdateDate: | 10/07/2013 | ||||||||
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| AuthorizedOfficialLastName: | SULLIVAN | ||||||||
| AuthorizedOfficialFirstName: | GERALD | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | SOLE MBR | ||||||||
| AuthorizedOfficialTelephone: | 4144479890 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RA0401X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Addiction Medicine |
No ID Information.