Basic Information
| Provider Information | |||||||||
| NPI: | 1508127705 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | QUAM | ||||||||
| FirstName: | CARLY | ||||||||
| MiddleName: | M. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | UTESH | ||||||||
| OtherFirstName: | CARLY | ||||||||
| OtherMiddleName: | M. | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | DO | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1241 S GRANT ROAD | ||||||||
| Address2: | |||||||||
| City: | CARROLL | ||||||||
| State: | IA | ||||||||
| PostalCode: | 51401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7127921500 | ||||||||
| FaxNumber: | 7127927597 | ||||||||
| Practice Location | |||||||||
| Address1: | 1241 S GRANT ROAD | ||||||||
| Address2: | |||||||||
| City: | CARROLL | ||||||||
| State: | IA | ||||||||
| PostalCode: | 51401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7127921500 | ||||||||
| FaxNumber: | 7127927597 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2012 | ||||||||
| LastUpdateDate: | 11/19/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 04481 | IA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.