Provider Demographics
NPI:1679653455
Name:SULLIVAN, MARK NICHOLAS (PT)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:NICHOLAS
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:575 PINE AVE
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:WI
Mailing Address - Zip Code:54634
Mailing Address - Country:US
Mailing Address - Phone:608-489-2733
Mailing Address - Fax:608-489-8193
Practice Address - Street 1:400 WATER AVE
Practice Address - Street 2:ST JOSEPHS REHAB DEPARTMENT
Practice Address - City:HILLSBORO
Practice Address - State:WI
Practice Address - Zip Code:54634
Practice Address - Country:US
Practice Address - Phone:608-489-8260
Practice Address - Fax:608-489-8193
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5549024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI5415000450861OtherDPI
WI40475300Medicaid