Healthcare Provider Details

I. General information

NPI: 1164817367
Provider Name (Legal Business Name): GANG QIU
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2015
Last Update Date: 04/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8090 ATLANTIC BLVD APT G92
JACKSONVILLE FL
32211-8573
US

IV. Provider business mailing address

8090 ATLANTIC BLVD APT G92
JACKSONVILLE FL
32211-8573
US

V. Phone/Fax

Practice location:
  • Phone: 856-796-0543
  • Fax:
Mailing address:
  • Phone: 856-796-0543
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247100000X
TaxonomyRadiologic Technologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: