Provider Demographics
NPI:1053431437
Name:QUAD CITIES INTERNAL MEDICINE PC
Entity type:Organization
Organization Name:QUAD CITIES INTERNAL MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:M
Authorized Official - Last Name:JAEGLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:563-359-5011
Mailing Address - Street 1:3509 SPRING ST
Mailing Address - Street 2:SUITE 3
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52807-2124
Mailing Address - Country:US
Mailing Address - Phone:563-359-5011
Mailing Address - Fax:359-355-3438
Practice Address - Street 1:3509 SPRING ST
Practice Address - Street 2:SUITE 3
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52807-2124
Practice Address - Country:US
Practice Address - Phone:563-359-5011
Practice Address - Fax:359-355-3438
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-30
Last Update Date:2013-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA27082207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0487322Medicaid
IA20088OtherWELLMARK
IA1057778Medicaid
IA20088OtherWELLMARK
IAE54124Medicare UPIN
IA0487322Medicaid