1174742753 NPI number — QUAL-T-MED, INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174742753 NPI number — QUAL-T-MED, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
QUAL-T-MED, 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:
1174742753
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
43 QUAIL WOODS DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FENTON
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63026-3444
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-422-7791
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1501 HAMPTON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAINT LOUIS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63139-3038
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-422-7791
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/24/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BURMEISTER
Authorized Official First Name:
RAY
Authorized Official Middle Name:
WILLIAM
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
314-849-6611

Provider Taxonomy Codes

  • Taxonomy code: 207RI0200X , with the licence number:  25858 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 290006733 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 07310 . This is a "GENCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1017503 . This is a "CARE PARTNERS" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 17745 . This is a "ANTHEM" identifier . This identifiers is of the category "OTHER".
  • Identifier: 100134 . This is a "HEALTHLINK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 200387736 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 92000 . This is a "UNITED HEALTHCARE" identifier . This identifiers is of the category "OTHER".




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