1942500913 NPI number — CAROLYN W. QUIST, DO, PA

Table of content: (NPI 1942500913)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942500913 NPI number — CAROLYN W. QUIST, DO, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CAROLYN W. QUIST, DO, PA
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:
1942500913
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/25/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1425 8TH AVENUE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT WORTH
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76104-4137
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-926-1313
Provider Business Mailing Address Fax Number:
817-926-7434

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1425 8TH AVENUE
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
FORT WORTH
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76104-4137
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-926-1313
Provider Business Practice Location Address Fax Number:
817-926-7434
Provider Enumeration Date:
10/25/2010

Additional Information

Authorized Official

Authorized Official Last Name:
QUIST
Authorized Official First Name:
CAROLYN
Authorized Official Middle Name:
W
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
817-926-1313

Provider Taxonomy Codes

  • Taxonomy code: 207V00000X , with the licence number:  H2705 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1649272972 . This is a "MEDICARE NPI" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 1255093-05 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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