Basic Information
Provider Information | |||||||||
NPI: | 1740521137 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | QSS-SOUTHEAST CLINICAL SERVICES LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 145 US HIGHWAY 46 | ||||||||
Address2: | SUITE 304 | ||||||||
City: | WAYNE | ||||||||
State: | NJ | ||||||||
PostalCode: | 074706830 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9738268287 | ||||||||
FaxNumber: | 8558345435 | ||||||||
Practice Location | |||||||||
Address1: | 4215 EDGEWATER DR | ||||||||
Address2: |   | ||||||||
City: | ORLANDO | ||||||||
State: | FL | ||||||||
PostalCode: | 328042206 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4075392000 | ||||||||
FaxNumber: | 4073980050 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/08/2013 | ||||||||
LastUpdateDate: | 07/19/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | NUESA | ||||||||
AuthorizedOfficialFirstName: | WILSON | ||||||||
AuthorizedOfficialMiddleName: | O | ||||||||
AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
AuthorizedOfficialTelephone: | 9738268287 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: | IV | ||||||||
AuthorizedOfficialCredential: | MBR | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X |   | FL | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |   |
No ID Information.