Provider Demographics
NPI:1124342407
Name:ADVANCED INTERNAL MEDICINE LLC
Entity type:Organization
Organization Name:ADVANCED INTERNAL MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:A
Authorized Official - Last Name:QUIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:765-472-3944
Mailing Address - Street 1:302 N DUKE ST
Mailing Address - Street 2:P.O. BOX 368
Mailing Address - City:PERU
Mailing Address - State:IN
Mailing Address - Zip Code:46970-1520
Mailing Address - Country:US
Mailing Address - Phone:765-472-3944
Mailing Address - Fax:765-472-3945
Practice Address - Street 1:302 N DUKE ST
Practice Address - Street 2:
Practice Address - City:PERU
Practice Address - State:IN
Practice Address - Zip Code:46970-1520
Practice Address - Country:US
Practice Address - Phone:765-472-3944
Practice Address - Fax:765-472-3945
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-16
Last Update Date:2013-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01045818261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200131050Medicaid
IN200131050Medicaid