Basic Information
Provider Information | |||||||||
NPI: | 1306348610 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | HEALTH QUEST MEDICAL PRACTICE, PC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | HQMP PHC SURG. ONC. | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1351 ROUTE 55 STE 200 | ||||||||
Address2: |   | ||||||||
City: | LAGRANGEVILLE | ||||||||
State: | NY | ||||||||
PostalCode: | 125405128 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8454759661 | ||||||||
FaxNumber: | 8454759938 | ||||||||
Practice Location | |||||||||
Address1: | 670 STONELEIGH AVE STE C126 | ||||||||
Address2: |   | ||||||||
City: | CARMEL | ||||||||
State: | NY | ||||||||
PostalCode: | 105123997 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8454836920 | ||||||||
FaxNumber: | 8454836922 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/02/2018 | ||||||||
LastUpdateDate: | 03/02/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LOOMIS | ||||||||
AuthorizedOfficialFirstName: | GLENN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CMO | ||||||||
AuthorizedOfficialTelephone: | 8454759661 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086X0206X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Surgical Oncology |
No ID Information.