Healthcare Provider Details

I. General information

NPI: 1265439020
Provider Name (Legal Business Name): STEPHEN GERARD QUILL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2005
Last Update Date: 01/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

771 OLD NORCROSS RD SUITE 300
LAWRENCEVILLE GA
30046-4386
US

IV. Provider business mailing address

771 OLD NORCROSS RD SUITE 300
LAWRENCEVILLE GA
30046-4386
US

V. Phone/Fax

Practice location:
  • Phone: 770-338-8362
  • Fax: 770-338-8364
Mailing address:
  • Phone: 770-338-8362
  • Fax: 770-338-8364

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number035321
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: