Healthcare Provider Details

I. General information

NPI: 1205919214
Provider Name (Legal Business Name): SULLIVAN MEDICAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 09/25/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11325 W EXPRESSWAY 83
SULLIVAN TX
78595
US

IV. Provider business mailing address

PO BOX 250
SULLIVAN CITY TX
78595-0250
US

V. Phone/Fax

Practice location:
  • Phone: 956-485-1401
  • Fax: 956-485-0107
Mailing address:
  • Phone: 956-485-1401
  • Fax: 956-485-1407

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0000X
TaxonomyAdolescent Medicine (Family Medicine) Physician
License Number
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number
License Number StateTX

VIII. Authorized Official

Name: MR. LOUIS GESLER MADHERE
Title or Position: CEO
Credential: PHYSICIAN ASSISTANT
Phone: 956-485-1401