Basic Information
| Provider Information | |||||||||
| NPI: | 1760683551 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SULLIVAN | ||||||||
| FirstName: | GERALD | ||||||||
| MiddleName: | EDWARD | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1169 N 13TH AVE | ||||||||
| Address2: | |||||||||
| City: | WEST BEND | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530901701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2623061997 | ||||||||
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| 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: | 05/30/2007 | ||||||||
| LastUpdateDate: | 08/12/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RA0401X | 37202 | WI | N | Allopathic & Osteopathic Physicians | Internal Medicine | Addiction Medicine | 207R00000X | 37202 | WI | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 32475500 | 05 | WI | MEDICAID |