Basic Information
| Provider Information | |||||||||
| NPI: | 1295022903 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SULLIVAN | ||||||||
| FirstName: | JOSEPH | ||||||||
| MiddleName: | |||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2000 E LAYTON AVE | ||||||||
| Address2: | |||||||||
| City: | ST FRANCIS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532356053 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4147446589 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2000 E LAYTON AVE | ||||||||
| Address2: | |||||||||
| City: | ST FRANCIS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532356053 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4147446589 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/01/2011 | ||||||||
| LastUpdateDate: | 11/24/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 65368-21 | WI | Y | Allopathic & Osteopathic Physicians | Surgery | 208600000X | 5101019532 | MI | N | Allopathic & Osteopathic Physicians | Surgery |
No ID Information.