1568490597 NPI number — QUANTUM HEALTHCARE MEDICAL ASSOCIATES INC.

Table of content: (NPI 1568490597)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568490597 NPI number — QUANTUM HEALTHCARE MEDICAL ASSOCIATES INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
QUANTUM HEALTHCARE MEDICAL ASSOCIATES INC.
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:
Provider Other Organization Name Type Code:
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:
1568490597
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/23/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1643 NW 136TH AVE STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SUNRISE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33323-2857
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-424-3672
Provider Business Mailing Address Fax Number:
954-377-3042

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
400 N PEPPER AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLTON
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92324-1801
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-580-1000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/29/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MANDAVIA
Authorized Official First Name:
SUJAL
Authorized Official Middle Name:
S.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
800-424-3672

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208M00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: DC7614 . This is a "MEDICARE RR" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: ZZZ00239Z . This is a "BS CALIFORNIA" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: ZZZ69383Z . This is a "BS OF CA - LODI" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: CH4064 . This is a "MEDICARE RR" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: ZZZ670892Z . This is a "BS OF CA - ST HELENA" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: GR0086343 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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