Healthcare Provider Details

I. General information

NPI: 1205263159
Provider Name (Legal Business Name): SULLIVAN MEDICAL CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/07/2013
Last Update Date: 10/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6040 W LISBON AVE SUITE 200
MILWAUKEE WI
53210-2116
US

IV. Provider business mailing address

6040 W LISBON AVE SUITE 200
MILWAUKEE WI
53210-2116
US

V. Phone/Fax

Practice location:
  • Phone: 414-447-9890
  • Fax: 414-447-9891
Mailing address:
  • Phone: 414-447-9890
  • Fax: 414-447-9891

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: GERALD E SULLIVAN
Title or Position: SOLE MBR
Credential: MD
Phone: 414-447-9890