1447350483 NPI number — TIMOTHY MICHAEL QUINN MD

Table of content: MRS. KATHRYN L GORDON PD, LE (NPI 1124387147)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447350483 NPI number — TIMOTHY MICHAEL QUINN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
QUINN
Provider First Name:
TIMOTHY
Provider Middle Name:
MICHAEL
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1447350483
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/10/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 750
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RIDGELAND
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39158-0750
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-899-3990
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
768 AVERY BLVD N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RIDGELAND
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39157-5219
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-487-6482
Provider Business Practice Location Address Fax Number:
601-487-6528
Provider Enumeration Date:
09/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  18002 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 51466372 . This is a "UNITED HEALTHCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 510466372 . This is a "MS HEALTH PARTNERS" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 0007359513 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 51046637239211A001 . This is a "TRICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 5104663720001 . This is a "CIGNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: P00072227 . This is a "MEDICARE RAILROAD MS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 03620330 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 510466732 . This is a "FIRST CHOICE" identifier . This identifiers is of the category "OTHER".




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