Provider Demographics
NPI:1558133678
Name:QUANN, MICHAEL ANTHONY
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ANTHONY
Last Name:QUANN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11470 COUNTY ROAD 1
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:OH
Mailing Address - Zip Code:45619-7010
Mailing Address - Country:US
Mailing Address - Phone:740-451-0074
Mailing Address - Fax:
Practice Address - Street 1:11470 COUNTY ROAD 1
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:OH
Practice Address - Zip Code:45619-7010
Practice Address - Country:US
Practice Address - Phone:740-451-0074
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-23
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1871150961Medicaid