Provider Demographics
NPI:1992114839
Name:EDWARD J. QUINN, M.D.
Entity type:Organization
Organization Name:EDWARD J. QUINN, M.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:J
Authorized Official - Last Name:QUINN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:928-855-5090
Mailing Address - Street 1:99 RIVIERA DR
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86403-5713
Mailing Address - Country:US
Mailing Address - Phone:928-855-5090
Mailing Address - Fax:
Practice Address - Street 1:99 RIVIERA DR
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-5713
Practice Address - Country:US
Practice Address - Phone:928-855-5090
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-05
Last Update Date:2014-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ31681174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZC96476Medicare UPIN