Provider Demographics
NPI:1568490597
Name:QUANTUM HEALTHCARE MEDICAL ASSOCIATES INC.
Entity Type:Organization
Organization Name:QUANTUM HEALTHCARE MEDICAL ASSOCIATES INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SUJAL
Authorized Official - Middle Name:S
Authorized Official - Last Name:MANDAVIA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:800-424-3672
Mailing Address - Street 1:1643 NW 136TH AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33323-2857
Mailing Address - Country:US
Mailing Address - Phone:800-424-3672
Mailing Address - Fax:954-377-3042
Practice Address - Street 1:400 N PEPPER AVE
Practice Address - Street 2:
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-1801
Practice Address - Country:US
Practice Address - Phone:909-580-1000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-29
Last Update Date:2020-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC7614OtherMEDICARE RR
CAZZZ00239ZOtherBS CALIFORNIA
CAZZZ69383ZOtherBS OF CA - LODI
CACH4064OtherMEDICARE RR
CAZZZ670892ZOtherBS OF CA - ST HELENA
CAGR0086343Medicaid
CAGR0086343Medicaid
CAZZZ670892ZOtherBS OF CA - ST HELENA
CACH4064OtherMEDICARE RR
CAZZZ05014ZMedicare PIN