Basic Information
| Provider Information | |||||||||
| NPI: | 1073714549 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | ZHAO | ||||||||
| FirstName: | ZHIQUAN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 707 E CEDAR ST | ||||||||
| Address2: | STE 200 | ||||||||
| City: | SOUTH BEND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 466172057 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5742512100 | ||||||||
| FaxNumber: | 5742512150 | ||||||||
| Practice Location | |||||||||
| Address1: | 6301 UNIVERSITY COMMONS STE 310 | ||||||||
| Address2: | OB/GYN OFFICE | ||||||||
| City: | SOUTH BEND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 466351479 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5742321471 | ||||||||
| FaxNumber: | 5742320741 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2007 | ||||||||
| LastUpdateDate: | 09/14/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 050379 | CT | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207V00000X | 01075003A | IN | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207VG0400X | 050379 | CT | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 201279260 | 05 | IN | MEDICAID | 000000934242 | 01 | IN | BCBS HOSP | OTHER | 1073714549 | 05 | CT | MEDICAID | 000000934270 | 01 | IN | BCBS FMC | OTHER |