Basic Information
Provider Information | |||||||||
NPI: | 1578203733 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | QC SUPPLEMENTAL ANESTHESIA STAFFING LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 689 | ||||||||
Address2: |   | ||||||||
City: | LAKE FOREST | ||||||||
State: | IL | ||||||||
PostalCode: | 600450689 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8004446110 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 4500 UTICA RIDGE RD | ||||||||
Address2: |   | ||||||||
City: | BETTENDORF | ||||||||
State: | IA | ||||||||
PostalCode: | 527221626 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5637425000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/29/2022 | ||||||||
LastUpdateDate: | 03/29/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SAHA | ||||||||
AuthorizedOfficialFirstName: | CHIRANJEEV | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | AUTHORIZED OFFICIAL | ||||||||
AuthorizedOfficialTelephone: | 7087147991 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: | 03/29/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |   |
No ID Information.