Provider Demographics
NPI:1790762227
Name:SULLIVAN, BRADLEY HUSE (MD)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:HUSE
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 1:6400 PROSPECT AVE
Mailing Address - Street 2:#598
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64132-4128
Mailing Address - Country:US
Mailing Address - Phone:816-444-6888
Mailing Address - Fax:816-444-1375
Practice Address - Street 1:6400 PROSPECT
Practice Address - Street 2:#598
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64132-4128
Practice Address - Country:US
Practice Address - Phone:816-444-6888
Practice Address - Fax:816-444-1375
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-27
Last Update Date:2010-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR6C60207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO208258004Medicaid
MO208258004Medicaid
MOG846425Medicare ID - Type Unspecified