Provider Demographics
NPI:1649618620
Name:XU, QIANQIAN (MD)
Entity type:Individual
Prefix:
First Name:QIANQIAN
Middle Name:
Last Name:XU
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 W JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62901-1462
Mailing Address - Country:US
Mailing Address - Phone:618-549-0721
Mailing Address - Fax:186-529-0479
Practice Address - Street 1:405 W JACKSON ST
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-1462
Practice Address - Country:US
Practice Address - Phone:618-549-0721
Practice Address - Fax:618-529-0449
Is Sole Proprietor?:No
Enumeration Date:2013-06-12
Last Update Date:2019-09-12
Deactivation Date:2014-04-03
Deactivation Code:
Reactivation Date:2014-05-08
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL036149072207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL214881OtherMEDICARE MULTISPECIALTY GROUP PTAN