1336132612 NPI number — DANIEL JOSEPH SULLIVAN MD

Table of content: DANIEL JOSEPH SULLIVAN MD (NPI 1336132612)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336132612 NPI number — DANIEL JOSEPH SULLIVAN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SULLIVAN
Provider First Name:
DANIEL
Provider Middle Name:
JOSEPH
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1336132612
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/08/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 5990, DEPT 20-6001
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CAROL STREAM
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60197-5990
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-785-9100
Provider Business Mailing Address Fax Number:
630-785-9199

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1 TRANSAM PLAZA DR
Provider Second Line Business Practice Location Address:
SUITE 360
Provider Business Practice Location Address City Name:
OAKBROOK TERRACE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60181-4822
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
630-785-9100
Provider Business Practice Location Address Fax Number:
630-785-9199
Provider Enumeration Date:
08/23/2005

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: 207P00000X , with the licence number:  42965020 , 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: 34087900 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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