Provider Demographics
NPI:1902911027
Name:SULLIVAN, WILLIAM P (DO)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:P
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21200 S LA GRANGE RD # 365
Mailing Address - Street 2:
Mailing Address - City:FRANKFORT
Mailing Address - State:IL
Mailing Address - Zip Code:60423-2003
Mailing Address - Country:US
Mailing Address - Phone:708-323-1015
Mailing Address - Fax:708-323-1015
Practice Address - Street 1:21200 S LA GRANGE RD # 365
Practice Address - Street 2:
Practice Address - City:FRANKFORT
Practice Address - State:IL
Practice Address - Zip Code:60423-2003
Practice Address - Country:US
Practice Address - Phone:708-323-1015
Practice Address - Fax:708-323-1015
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-20
Last Update Date:2016-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036088666207P00000X
IN02001489A207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
F86187Medicare UPIN
L65199Medicare ID - Type Unspecified