Provider Demographics
NPI:1619929478
Name:SULLIVAN, KENNETH P (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:P
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 1:1121 LAKE COOK ROAD
Mailing Address - Street 2:SUITE M
Mailing Address - City:DEERFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60015-5234
Mailing Address - Country:US
Mailing Address - Phone:847-945-4550
Mailing Address - Fax:847-948-8103
Practice Address - Street 1:1416C SOUTH RANDALL ROAD
Practice Address - Street 2:RANDALL SQUARE SHOPPING CENTER
Practice Address - City:GENEVA
Practice Address - State:IL
Practice Address - Zip Code:60134-4682
Practice Address - Country:US
Practice Address - Phone:630-208-9325
Practice Address - Fax:630-208-9326
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2085N0700X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
Not Answered2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
C44551Medicare UPIN
ILL05028Medicare ID - Type Unspecified
ILK07634Medicare ID - Type Unspecified