1346438389 NPI number — QUALITY CARE INTERNAL MEDICINE OF NORTH AMERICA

Table of content: (NPI 1346438389)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346438389 NPI number — QUALITY CARE INTERNAL MEDICINE OF NORTH AMERICA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
QUALITY CARE INTERNAL MEDICINE OF NORTH AMERICA
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:
1346438389
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/09/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1121
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLUMBIA
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39429-1121
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-444-9266
Provider Business Mailing Address Fax Number:
601-444-9267

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1212 BROAD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLUMBIA
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39429-3114
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-444-9266
Provider Business Practice Location Address Fax Number:
601-444-9267
Provider Enumeration Date:
10/03/2007

Additional Information

Authorized Official

Authorized Official Last Name:
UGWU-DIKE
Authorized Official First Name:
MARTINS
Authorized Official Middle Name:
THADDEUS
Authorized Official Title or Position:
PRESIDENT/OWNER
Authorized Official Telephone Number:
601-444-9266

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  15631R , 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: 09308872 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: DN7784 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 408819123B . This is a "BLUE CROSS BLUE SHIELD MS" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".




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