MEDICARE: DR. ANDREW SCOTT QUALM O.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	152W00000X	Optometrist	170	SD

General Provider Information

NPI Number	:	1881669661
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ANDREW SCOTT QUALM O.D.

Provider Business Mailing Address
First Line	:	23805 PLACER PL
Second Line	:
City	:	RAPID CITY
State	:	SD
Zip	:	57702-6573
Country	:	US
Telephone Number	:	605-574-2297
Fax Number	:	605-455-1529

Provider Business Practice Location Address
First Line	:	1000 HEALTH CENTER ROAD
Second Line	:
City	:	KYLE
State	:	SD
Zip	:	57752
Country	:	US
Telephone Number	:	605-455-8216
Fax Number	:	605-455-1529

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

Provider Enumeration Date	:	02/23/2006
Last Update Date	:	07/08/2007

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