Basic Information
| Provider Information | |||||||||
| NPI: | 1417921560 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | QUINCY PHYSICIANS & SURGEONS CLINIC, PLLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | QUNCY MEDICAL GROUP PHARMACY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1025 MAINE ST | ||||||||
| Address2: | |||||||||
| City: | QUINCY | ||||||||
| State: | IL | ||||||||
| PostalCode: | 623014038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2172226550 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1025 MAINE ST | ||||||||
| Address2: | |||||||||
| City: | QUINCY | ||||||||
| State: | IL | ||||||||
| PostalCode: | 623014038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2172226550 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2006 | ||||||||
| LastUpdateDate: | 12/20/2021 | ||||||||
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| AuthorizedOfficialLastName: | WOERMAN | ||||||||
| AuthorizedOfficialFirstName: | PATTY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 2172226550 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 12/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X | 004000187 | IL | Y | Suppliers | Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 004000187 | 01 | IL | WHOLESALE DISTRIBU LICENS | OTHER |