Provider Demographics
NPI:1467631507
Name:MARQUARDT PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:MARQUARDT PROFESSIONAL CORPORATION
Other - Org Name:MOAB IMMEDIATE CARE AND XRAY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT, MARQUARDT PROF CORP
Authorized Official - Prefix:DR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:NILAN
Authorized Official - Last Name:MARQUARDT
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PHD
Authorized Official - Phone:435-259-5276
Mailing Address - Street 1:267 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MOAB
Mailing Address - State:UT
Mailing Address - Zip Code:84532-2342
Mailing Address - Country:US
Mailing Address - Phone:435-259-5276
Mailing Address - Fax:435-259-5277
Practice Address - Street 1:267 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MOAB
Practice Address - State:UT
Practice Address - Zip Code:84532-2342
Practice Address - Country:US
Practice Address - Phone:435-259-5276
Practice Address - Fax:435-259-5277
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-25
Last Update Date:2007-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1623961205261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTC63419Medicare UPIN