MEDICARE: QING IVY FAN MD

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	207R00000X	Internal Medicine Physician	0000040237	TN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1679520365
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	QING IVY FAN MD

Provider Business Mailing Address
First Line	:	6817 SOUTHPOINT PKWY
Second Line	:	#503
City	:	JACKSONVILLE
State	:	FL
Zip	:	32216-6282
Country	:	US
Telephone Number	:	904-296-9777
Fax Number	:	904-296-9977

Provider Business Practice Location Address
First Line	:	6817 SOUTHPOINT PKWY
Second Line	:	#503
City	:	JACKSONVILLE
State	:	FL
Zip	:	32216-6282
Country	:	US
Telephone Number	:	904-296-9777
Fax Number	:	904-296-9977

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

Provider Enumeration Date	:	05/28/2006
Last Update Date	:	09/18/2008

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Directions to “ QING IVY FAN MD” Practice Location

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