1760683551 NPI number — DR. GERALD EDWARD SULLIVAN M.D.

Table of content: DR. GERALD EDWARD SULLIVAN M.D. (NPI 1760683551)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760683551 NPI number — DR. GERALD EDWARD SULLIVAN M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SULLIVAN
Provider First Name:
GERALD
Provider Middle Name:
EDWARD
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1760683551
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/12/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1169 N 13TH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WEST BEND
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53090-1701
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
262-306-1997
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6040 W LISBON AVE
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
MILWAUKEE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53210-2116
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-447-9890
Provider Business Practice Location Address Fax Number:
414-447-9891
Provider Enumeration Date:
05/30/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RA0401X , with the licence number:  37202 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: 37202 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 32475500 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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