NPIMap

Individual provider Active NPI

Shannon Marie Sullivan, M.D.

  • Family Medicine Physician
  • Menasha, WI
National Provider Identifier
1972998680
Registry record updated Sep 13, 2018
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
License
66251 Issued in WI
Practice address
2005 Midway Rd
Menasha, WI 54952
Phone
(920) 832-8500
Fax
(920) 993-2919
NPI assigned
Mar 31, 2015
Sex
Female
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Sep 13, 2018

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

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X 66251 WI Primary

Addresses

Primary practice location

2005 Midway Rd
Menasha, WI 54952

Mailing address

122 E College Ave
Appleton, WI 54911-5794
Phone (920) 996-3264

Other practice location 1

1121 E North Ave
Milwaukee, WI 53212-3515
Phone (414) 267-6502

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in WI
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20181002000755 WI Practitioner - Family Practice 8820365976 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Family Practice
Education
Loyola University of Chicago, Stritch School of Medicine, 2015
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Telehealth
Offers telehealth services
Group practices
Thedacare, IncorporatedGroup PAC ID 1759294887, 654 clinicians

Practice addresses (Care Compare)

2005 Midway Rd
Menasha, WI 54952-7002
Phone (920) 832-8500

Hospital & facility affiliations

  • Thedacare Regional Med Ctr - Neenah Hospital, Neenah, WI, CCN 520045
  • Thedacare Regional Medical Center - Appleton Inc Hospital, Appleton, WI, CCN 520160

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Medicine

Practice roles

OrganizationSpecialtyStatusNew patients
Thedacare, Incorporated CurrentSince Sep 17, 2018 Accepting new patients
Thedacare, Incorporated Family Medicine CurrentSince Sep 17, 2018 Accepting new patients
Thedacare Medical Center - Berlin, Inc. Past Accepting new patients

Locations

4480 W Spencer St
Appleton, WI 54914
Phone (920) 738-4800

122 E College Ave
Appleton, WI 54911
Phone (920) 996-3264

2005 Midway Rd
Menasha, WI 54952
Phone (920) 380-4812

1405 Mill St
New London, WI 54961
Phone (920) 531-2000

600 N Westhaven Dr
Oshkosh, WI 54904
Phone (920) 237-5000

Interoperability endpoints

  • Direct secure messaging: ssullivan191046@direct.thedacare.org

Organizations & group practices 3

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

Hospital & facility affiliations 12

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

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

{
    "created_epoch": "1427760000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1536796800000",
    "number": "1972998680",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "122 E COLLEGE AVE",
            "city": "APPLETON",
            "state": "WI",
            "postal_code": "549115794",
            "telephone_number": "920-996-3264",
            "fax_number": "920-830-5910"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2005 MIDWAY RD",
            "city": "MENASHA",
            "state": "WI",
            "postal_code": "54952",
            "telephone_number": "920-832-8500",
            "fax_number": "920-993-2919"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "1121 E North Ave",
            "address_purpose": "LOCATION",
            "city": "Milwaukee",
            "state": "WI",
            "postal_code": "532123515",
            "country_code": "US",
            "telephone_number": "414-267-6502",
            "fax_number": "414-267-3892",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "SULLIVAN",
        "first_name": "SHANNON",
        "middle_name": "MARIE",
        "name_prefix": "Dr.",
        "credential": "M.D.",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2015-03-31",
        "last_updated": "2018-09-13",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "WI",
            "license": "66251",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Menasha, WI

Sources for this page

Verify at the official NPI Registry.