Provider Demographics
NPI:1568650158
Name:GULLY, JONATHAN (MD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:GULLY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9200 W WISCONSIN AVE
Mailing Address - Street 2:PALLIATIVE CARE-CANCER CENTER BUILDING
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3522
Mailing Address - Country:US
Mailing Address - Phone:414-805-4607
Mailing Address - Fax:414-805-4608
Practice Address - Street 1:9200 W WISCONSIN AVE
Practice Address - Street 2:PALLIATIVE CARE-CANCER CENTER BUILDING
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3522
Practice Address - Country:US
Practice Address - Phone:414-805-4607
Practice Address - Fax:414-805-4608
Is Sole Proprietor?:No
Enumeration Date:2007-10-09
Last Update Date:2013-11-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA235276207R00000X
WI53292-020208000000X
WI53292207RH0003X, 207RH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1568650158Medicaid
WI1568650158Medicaid
WI68086 1092Medicare PIN