MEDICARE: DR. LONG THANG QUAN M.D., PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207N00000X	Dermatology Physician	22472	SC

General Provider Information

NPI Number	:	1194784058
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LONG THANG QUAN M.D., PH.D.

Provider Business Mailing Address
First Line	:	1706 SAINT JULIAN PL
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29204-2410
Country	:	US
Telephone Number	:	803-771-7506
Fax Number	:	803-771-9455

Provider Business Practice Location Address
First Line	:	1706 SAINT JULIAN PL
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29204-2410
Country	:	US
Telephone Number	:	803-771-7506
Fax Number	:	803-771-9455

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/20/2006
Last Update Date	:	10/09/2007

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