MEDICARE: TIMOTHY ELLIS QUINN IDC

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	246Z00000X	Other Specialist/Technologist

General Provider Information

NPI Number	:	1790755890
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TIMOTHY ELLIS QUINN IDC

Provider Business Mailing Address
First Line	:	609 CHABLIS DR
Second Line	:
City	:	KENNER
State	:	LA
Zip	:	70065-1741
Country	:	US
Telephone Number	:	504-678-2400
Fax Number	:

Provider Business Practice Location Address
First Line	:	NAVAL AMBULATORY CARE CENTER
Second Line	:	2300 GENERAL MEYER AV BLDG H-100
City	:	NEW ORLEANS
State	:	LA
Zip	:	70142-0001
Country	:	US
Telephone Number	:	504-678-2400
Fax Number	:

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

Provider Enumeration Date	:	01/23/2006
Last Update Date	:	07/08/2007

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