1053410001 NPI number — QUINCY PHYSICIANS & SURGEONS CLINIC, PLLC

Table of content: (NPI 1053410001)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053410001 NPI number — QUINCY PHYSICIANS & SURGEONS CLINIC, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
QUINCY PHYSICIANS & SURGEONS CLINIC, PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
QUINCY MEDICAL GROUP
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053410001
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/10/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1025 MAINE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
QUINCY
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62301-4038
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
217-222-6550
Provider Business Mailing Address Fax Number:
217-277-2253

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1025 MAINE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
QUINCY
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62301-4038
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
217-222-6550
Provider Business Practice Location Address Fax Number:
217-277-2253
Provider Enumeration Date:
09/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WILLIAMSON
Authorized Official First Name:
PATRICIA
Authorized Official Middle Name:
A.
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
217-222-6550

Provider Taxonomy Codes

  • Taxonomy code: 261QE0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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