Basic Information
| Provider Information | |||||||||
| NPI: | 1093817157 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | QUILLIAN | ||||||||
| FirstName: | CATHLEEN | ||||||||
| MiddleName: | WOOD | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1501 COLLIERS CREEK RD | ||||||||
| Address2: | |||||||||
| City: | WATKINSVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30677 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7067694141 | ||||||||
| FaxNumber: | 9123508067 | ||||||||
| Practice Location | |||||||||
| Address1: | 1107 E 66TH ST | ||||||||
| Address2: | |||||||||
| City: | SAVANNAH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 314045701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9123508404 | ||||||||
| FaxNumber: | 9123508067 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/01/2006 | ||||||||
| LastUpdateDate: | 06/02/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 045924 | GA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000904615A | 01 | GA | MEDICAID ID FROM OLD GROUP | OTHER | 08BBVCP | 01 | GA | MEDICARE PTAN FROM OLD GROUP | OTHER | GA1017 | 05 | SC | MEDICAID | P00778527 | 01 | GA | RR MEDICARE | OTHER | 296899578B | 05 | GA | MEDICAID |