Provider Demographics
NPI:1104919869
Name:SULLIVAN EYE CENTER, S.C.
Entity type:Organization
Organization Name:SULLIVAN EYE CENTER, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:D
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:920-734-0400
Mailing Address - Street 1:1195 N CASALOMA DR
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54913-9295
Mailing Address - Country:US
Mailing Address - Phone:920-734-0400
Mailing Address - Fax:920-734-9054
Practice Address - Street 1:1195 N CASALOMA DR
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54913-9295
Practice Address - Country:US
Practice Address - Phone:920-734-0400
Practice Address - Fax:920-734-9054
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2008-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2483-035152W00000X
WI2752-035152W00000X
WI2681-035152W00000X
WI18799207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38455900Medicaid
WI38455900Medicaid
0533940001Medicare NSC
000045385Medicare PIN