Basic Information
| Provider Information | |||||||||
| NPI: | 1902822950 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LI | ||||||||
| FirstName: | QIN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1400 BLACKHORSE HILL RD | ||||||||
| Address2: | PRIMARY CARE DEVISION | ||||||||
| City: | COATESVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 193202040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6103847711 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1400 BLACKHORSE HILL RD | ||||||||
| Address2: | PRIMARY CARE DEVISION | ||||||||
| City: | COATESVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 193202040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6103847711 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2006 | ||||||||
| LastUpdateDate: | 08/07/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 25MA07771800 | NJ | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 108031VHT | 01 | NJ | MEDICARE | OTHER | 112810 | 05 | NJ | MEDICAID |