Basic Information
| Provider Information | |||||||||
| NPI: | 1720020092 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PUA | ||||||||
| FirstName: | QUIRINO | ||||||||
| MiddleName: | LIM | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1164 | ||||||||
| Address2: | |||||||||
| City: | DALTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 307221164 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7062710100 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2505 US HIGHWAY 431 | ||||||||
| Address2: | |||||||||
| City: | BOAZ | ||||||||
| State: | AL | ||||||||
| PostalCode: | 359575908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2588403480 | ||||||||
| FaxNumber: | 2568403626 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2006 | ||||||||
| LastUpdateDate: | 07/09/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 9242 | AL | N | Other Service Providers | Specialist | 2085R0202X | 9242 | AL | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 051517352 | 05 | AL | MEDICAID |