Provider Demographics
NPI:1770565608
Name:QUIRK, MARILOU T (NP-C)
Entity type:Individual
Prefix:
First Name:MARILOU
Middle Name:T
Last Name:QUIRK
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 452
Mailing Address - Street 2:
Mailing Address - City:UNION CITY
Mailing Address - State:IN
Mailing Address - Zip Code:47390-0452
Mailing Address - Country:US
Mailing Address - Phone:765-964-4200
Mailing Address - Fax:765-964-4300
Practice Address - Street 1:6000 W COUNTY ROAD 400 N
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47304-9057
Practice Address - Country:US
Practice Address - Phone:765-289-9709
Practice Address - Fax:765-964-4300
Is Sole Proprietor?:No
Enumeration Date:2005-11-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71001754A363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000351540OtherBC/BS
IN200494420AMedicaid
IN2TB5910Medicare ID - Type UnspecifiedMEDICARE #
INQ26314Medicare UPIN
IN200494420AMedicaid