Basic Information
| Provider Information | |||||||||
| NPI: | 1114966611 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NYQUIST | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4500 MEMORIAL DR | ||||||||
| Address2: | |||||||||
| City: | BELLEVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622265360 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182576220 | ||||||||
| FaxNumber: | 6182576679 | ||||||||
| Practice Location | |||||||||
| Address1: | 4500 MEMORIAL DR | ||||||||
| Address2: | |||||||||
| City: | BELLEVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62226 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182576220 | ||||||||
| FaxNumber: | 6182576679 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2006 | ||||||||
| LastUpdateDate: | 02/23/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 36076188 | IL | N | Allopathic & Osteopathic Physicians | Family Medicine | 208M00000X | 036-076188 | IL | Y | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 187771 | 01 | HEALTH LINK | OTHER | 0104775 | 01 | UNITED HEALTH CARE UHC | OTHER | 080174497 | 01 | RAILROAD MEDICARE | OTHER | 036076188 | 05 | IL | MEDICAID | 133289 | 01 | CMR A DIVISION OF GHP | OTHER | 006015346 | 01 | IL | BLUE CROSS BLUE SHIELD OF | OTHER | 4080250 | 01 | AETNA | OTHER | 133289 | 01 | GROUP HEALTH PLAN GHP | OTHER |