Provider Demographics
NPI:1780850982
Name:QUINCY INTERMED INC
Entity type:Organization
Organization Name:QUINCY INTERMED INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLER
Authorized Official - Prefix:
Authorized Official - First Name:HEIDI
Authorized Official - Middle Name:L
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:517-639-5354
Mailing Address - Street 1:185 E CHICAGO ST
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:MI
Mailing Address - Zip Code:49082-1165
Mailing Address - Country:US
Mailing Address - Phone:517-639-5354
Mailing Address - Fax:517-639-5344
Practice Address - Street 1:185 E CHICAGO ST
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:MI
Practice Address - Zip Code:49082-1165
Practice Address - Country:US
Practice Address - Phone:517-639-5354
Practice Address - Fax:517-639-5344
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-07
Last Update Date:2008-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704213726363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4934955Medicaid
MI1932284973OtherNPI TYPE 1
MI0P21870003Medicare PIN
MIQ73858Medicare UPIN