1841712254 NPI number — QLER PHYSICIAN MEDICAL GROUP, P.A.

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 1841712254 NPI number — QLER PHYSICIAN MEDICAL GROUP, P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
QLER PHYSICIAN MEDICAL GROUP, P.A.
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:
1841712254
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/30/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
200 W MARTIN LUTHER KING BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHATTANOOGA
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37402-2560
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
240-285-5396
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4431 ADRIENNE CT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JEFFERSON
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21755
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
240-285-5396
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/07/2017

Additional Information

Authorized Official

Authorized Official Last Name:
NARAYAN
Authorized Official First Name:
DWAYNE
Authorized Official Middle Name:
AVANISH
Authorized Official Title or Position:
CHIEF CLINICAL OFFICER
Authorized Official Telephone Number:
240-285-5396

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2084P0804X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208D00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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