Provider Demographics
NPI:1932141348
Name:QI WAN MD PC
Entity Type:Organization
Organization Name:QI WAN MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:QI
Authorized Official - Middle Name:
Authorized Official - Last Name:WAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:256-650-0275
Mailing Address - Street 1:333 WHITESPORT DR SW
Mailing Address - Street 2:STE 303
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35801-3455
Mailing Address - Country:US
Mailing Address - Phone:256-650-0275
Mailing Address - Fax:256-881-0468
Practice Address - Street 1:333 WHITESPORT DR SW
Practice Address - Street 2:STE 303
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35801-3455
Practice Address - Country:US
Practice Address - Phone:256-650-0275
Practice Address - Fax:256-881-0468
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-11
Last Update Date:2008-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL21622207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51519742OtherBCBS OF AL PROVIDER #
AL51519742OtherBCBS OF AL PROVIDER #
AL5034720001Medicare NSC