1083980932 NPI number — MR. ERNEST THEOPHILUS QUIMBY IV IDC

Table of content: MR. ERNEST THEOPHILUS QUIMBY IV IDC (NPI 1083980932)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083980932 NPI number — MR. ERNEST THEOPHILUS QUIMBY IV IDC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
QUIMBY
Provider First Name:
ERNEST
Provider Middle Name:
THEOPHILUS
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
IV
Provider Credential Text:
IDC
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:
1083980932
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/30/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
WALTER REED NMMC
Provider Second Line Business Mailing Address:
BLDG 1 SUITE 5103 8955 WOOD ROAD
Provider Business Mailing Address City Name:
BETHESDA
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20889-5628
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
WALTER REED NMMC
Provider Second Line Business Practice Location Address:
BLDG 1 SUITE 5103 8955 WOOD ROAD
Provider Business Practice Location Address City Name:
BETHESDA
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20889-5628
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
202-319-4440
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/26/2012

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: 1710I1002X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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