NPIMap

Organization Active NPI

Sullivan Medical Clinic, LLC

  • Addiction Medicine (Internal Medicine) Physician
  • Milwaukee, WI
National Provider Identifier
1205263159
Registry record updated Oct 7, 2013
On this page

Key facts

NPPES NPI Registry
Primary specialty
Addiction Medicine (Internal Medicine) PhysicianTaxonomy code 207RA0401X
Legal business name
SULLIVAN MEDICAL CLINIC, LLC
Practice address
6040 W Lisbon Ave
Suite 200
Milwaukee, WI 53210-2116
Phone
(414) 447-9890
Fax
(414) 447-9891
NPI assigned
Oct 7, 2013
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Oct 7, 2013

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Gerald E Sullivan, MDNPI 1760683551
Title
Sole MBR
Phone
(414) 447-9890

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Addiction Medicine (Internal Medicine) PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 207RA0401X Primary

Addresses

Primary practice location

6040 W Lisbon Ave
Suite 200
Milwaukee, WI 53210-2116

Mailing address

6040 W Lisbon Ave
Suite 200
Milwaukee, WI 53210-2116
Phone (414) 447-9890

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in WI

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20140221000634 WI Part B Supplier - Clinic/Group Practice 7214167196 Receives reassigned benefits from 1 practitioner
Practice locations: Milwaukee, WI

National Provider Directory

National Provider Directory

Locations

2949 N Dr Martin Luther King Dr
Milwaukee, WI 53212
Phone (414) 265-5940

6815 W Capitol Dr
Ste 105A
Milwaukee, WI 53216
Phone (414) 447-9890

4222 W Capitol Dr
Ste 300
Milwaukee, WI 53216
Phone (414) 447-9890

Practitioners & affiliated clinicians

Practitioners 10

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1381104000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1381104000000",
    "number": "1205263159",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "6040 W LISBON AVE",
            "address_2": "SUITE 200",
            "city": "MILWAUKEE",
            "state": "WI",
            "postal_code": "532102116",
            "telephone_number": "414-447-9890",
            "fax_number": "414-447-9891"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "6040 W LISBON AVE",
            "address_2": "SUITE 200",
            "city": "MILWAUKEE",
            "state": "WI",
            "postal_code": "532102116",
            "telephone_number": "414-447-9890",
            "fax_number": "414-447-9891"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SULLIVAN MEDICAL CLINIC, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2013-10-07",
        "last_updated": "2013-10-07",
        "status": "A",
        "authorized_official_last_name": "SULLIVAN",
        "authorized_official_first_name": "GERALD",
        "authorized_official_middle_name": "E",
        "authorized_official_title_or_position": "SOLE MBR",
        "authorized_official_telephone_number": "414-447-9890",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "207RA0401X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Internal Medicine, Addiction Medicine",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Milwaukee, WI

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 7, 2013; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.