Basic Information
Provider Information | |||||||||
NPI: | 1578098240 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | QUINN | ||||||||
FirstName: | IAN | ||||||||
MiddleName: | CHRISTOPHER | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.O. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 658 | ||||||||
Address2: |   | ||||||||
City: | GAINESVILLE | ||||||||
State: | GA | ||||||||
PostalCode: | 305030658 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7707181122 | ||||||||
FaxNumber: | 7705334786 | ||||||||
Practice Location | |||||||||
Address1: | 1270 FRIENDSHIP RD. | ||||||||
Address2: |   | ||||||||
City: | BRASELTON | ||||||||
State: | GA | ||||||||
PostalCode: | 305173051 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6782074050 | ||||||||
FaxNumber: | 6782074051 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/01/2017 | ||||||||
LastUpdateDate: | 12/15/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/29/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 89636 | GA | N |   | Allopathic & Osteopathic Physicians | Family Medicine |   | 207Q00000X | 2020-02252 | NC | N |   | Allopathic & Osteopathic Physicians | Family Medicine |   | 207QS0010X | 2020-02252 | NC | N |   | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine | 390200000X |   |   | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   | 207QS0010X | 89636 | GA | Y |   | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine |
No ID Information.