Basic Information
| Provider Information | |||||||||
| NPI: | 1619929478 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SULLIVAN | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | P | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1121 LAKE COOK ROAD | ||||||||
| Address2: | SUITE M | ||||||||
| City: | DEERFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600155234 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8479454550 | ||||||||
| FaxNumber: | 8479488103 | ||||||||
| Practice Location | |||||||||
| Address1: | 1416C SOUTH RANDALL ROAD | ||||||||
| Address2: | RANDALL SQUARE SHOPPING CENTER | ||||||||
| City: | GENEVA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601344682 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6302089325 | ||||||||
| FaxNumber: | 6302089326 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085N0700X | IL | X | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology | 2085R0202X | IL | X | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.