NPIMap

Organization Active NPI

Quincy Physicians & Surgeons Clinic, PLLC

Doing business as Quincy Medical Group Canton Affiliate

  • Rural Health Clinic/Center
  • Canton, MO
National Provider Identifier
1902870439
Registry record updated Dec 20, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
QUINCY PHYSICIANS & SURGEONS CLINIC, PLLC
Doing business as
Quincy Medical Group Canton Affiliate
Practice address
1100 E Outer Rd S Ste 4
Canton, MO 63435-1702
Phone
(573) 288-5949
Fax
(573) 288-5755
NPI assigned
Feb 13, 2006
Last updated
Dec 20, 2021By the provider in NPPES
Organization subpart
Yes
Parent organization
QUINCY PHYSICIANS & SURGEONS CLINIC, PLLCAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Dec 20, 2021

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Dan EvansNPI 1730152273
Title
Ceo
Phone
(217) 222-6550

Authorized official NPPES reports the official by name only. The link goes to the one practitioner with that name whose NPPES practice address or phone number is this organization’s.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Rural Health Clinic/Center 261QR1300X NU Primary

Addresses

Primary practice location

1100 E Outer Rd S Ste 4
Canton, MO 63435-1702

Mailing address

1025 Maine St
Quincy, IL 62301-4038
Phone (217) 222-6550

Other practice location 1

1025 Maine St
Quincy, IL 62301-4038
Phone (217) 222-6550

Other names 1

  • QUINCY MEDICAL GROUP CANTON AFFILIATE Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MO

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20101105000872 MO Part A Provider - Rural Health Clinic 0749192375 Practice locations: Canton, MO

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1902870439. Details of each certification follow.

Rural health clinic certification: CCN 263836

Legal name
QUINCY PHYSICIANS & SURGEONS CLINIC, PLLC
Doing business as
QUINCY MEDICAL GROUP CANTON AFFILIATE
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Aug 11, 1994
Last certification
Oct 26, 2021
Ownership / control type
2A
Organization structure
LLCProprietary
Incorporated
Jan 1, 1987 in IL
Enrollment address
1100 E Outer Road South
Canton, MO 63435-1702

Other NPIs with the same Medicare PAC ID 17

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

View all 17

National Provider Directory

National Provider Directory
Tax ID family
Quincy Med GRP Lewistow25 organizations share this tax ID, including this one
Part of
Quincy Med GRP Lewistow

Other organizations with this tax ID 24

Organizations that report the same tax identification number in the National Provider Directory.

View all 24

Ownership & related parties

All disclosed owners & managing parties 3

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Quincy Physician Administrative Services Inc Organization, Quincy, IL Corporation, Management services company Operational/Managerial Control Dec 3, 2021
Hrishikesh P Ghanekar Individual Corporate DirectorChairman of the Board Jan 1, 2018
W-2 Managing EmployeeChairman of the Board Jan 13, 2026
Patricia a Woerman Individual W-2 Managing EmployeeCredentialing Specialist and del May 19, 2010

Owners & managing parties with NPI records 1

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

Facilities with the same owner 5

Facilities that share an organizational owner with 5% or greater ownership or operational control.

Practitioners & affiliated clinicians

Practitioners 2

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1139788800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1639958400000",
    "number": "1902870439",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1025 MAINE ST",
            "city": "QUINCY",
            "state": "IL",
            "postal_code": "623014038",
            "telephone_number": "217-222-6550"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1100 E OUTER RD S STE 4",
            "city": "CANTON",
            "state": "MO",
            "postal_code": "634351702",
            "telephone_number": "573-288-5949",
            "fax_number": "573-288-5755"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "1025 Maine St",
            "address_purpose": "LOCATION",
            "city": "Quincy",
            "state": "IL",
            "postal_code": "623014038",
            "country_code": "US",
            "telephone_number": "217-222-6550",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "organization_name": "QUINCY PHYSICIANS & SURGEONS CLINIC, PLLC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "QUINCY PHYSICIANS & SURGEONS CLINIC, PLLC",
        "enumeration_date": "2006-02-13",
        "last_updated": "2021-12-20",
        "certification_date": "2021-12-20",
        "status": "A",
        "authorized_official_last_name": "EVANS",
        "authorized_official_first_name": "DAN",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "217-222-6550",
        "authorized_official_name_prefix": "Dr."
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "QUINCY MEDICAL GROUP CANTON AFFILIATE",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "QUINCY MEDICAL GROUP CANTON AFFILIATE",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Canton, MO

Sources for this page

Verify at the official NPI Registry.