MEDICARE: QI WAN MD PC

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	21622	AL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	51519742	OTHER	AL	BCBS OF AL PROVIDER #

General Provider Information

NPI Number	:	1932141348
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	QI WAN MD PC

Provider Business Mailing Address
First Line	:	333 WHITESPORT DR SW
Second Line	:	STE 303
City	:	HUNTSVILLE
State	:	AL
Zip	:	35801-3455
Country	:	US
Telephone Number	:	256-650-0275
Fax Number	:	256-881-0468

Provider Business Practice Location Address
First Line	:	333 WHITESPORT DR SW
Second Line	:	STE 303
City	:	HUNTSVILLE
State	:	AL
Zip	:	35801-3455
Country	:	US
Telephone Number	:	256-650-0275
Fax Number	:	256-881-0468

Authorized Official
Title or Position	:	OWNER
Name	:	DR. QI WAN
Credential	:	MD
Telephone Number	:	256-650-0275

Provider Enumeration Date	:	06/11/2006
Last Update Date	:	02/05/2008

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Directions to “QI WAN MD PC ” Practice Location

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