Provider Demographics
NPI:1902899917
Name:SULLIVAN, KENNETH (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:BERLIN
Mailing Address - State:WI
Mailing Address - Zip Code:54923-1243
Mailing Address - Country:US
Mailing Address - Phone:920-361-1313
Mailing Address - Fax:
Practice Address - Street 1:225 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:BERLIN
Practice Address - State:WI
Practice Address - Zip Code:54923-1243
Practice Address - Country:US
Practice Address - Phone:920-361-5525
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI40493-020207P00000X, 207Q00000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Not Answered208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32483800Medicaid
WI32483800Medicaid