| Name: | Qi Wan, MD, LLC |
| Jurisdiction: | Alabama |
| Legal type: | Domestic Limited Liability Company |
| Status: | Dissolved |
| Date of registration: | 20 Nov 2003 (21 years ago) |
| Date of dissolution: | 20 Feb 2004 |
| Entity Number: | 000-695-128 |
| Register Number: | 000695128 |
| County: | Madison |
| Place of Formation: | Madison County |
| Principal Address: | HUNTSVILLE, AL |
| Registered Office Street Address: | 610 AIRPORT RD STE 204HUNTSVILLE, AL 35802 |
| Registered Office Street Address ZIP Code: | 35802 |
Activities
INTERNAL MEDICINE PRACTICE
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1932141348 | 2006-06-11 | 2008-02-05 | 333 WHITESPORT DR SW, STE 303, HUNTSVILLE, AL, 358013455, US | 333 WHITESPORT DR SW, STE 303, HUNTSVILLE, AL, 358013455, US | |||||||||||||||||||||||||
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| Phone | +1 256-650-0275 |
| Fax | 2568810468 |
Authorized person
| Name | DR. QI WAN |
| Role | OWNER |
| Phone | 2566500275 |
Taxonomy
| Taxonomy Code | 207R00000X - Internal Medicine Physician |
| License Number | 21622 |
| State | AL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | BCBS OF AL PROVIDER # |
| Number | 51519742 |
| State | AL |
| Name | Role |
|---|---|
| WAN, QI | Agent |
| Name | Role |
|---|---|
| WAN, QI | Member |
Date of last update: 15 Aug 2024
Sources: Alabama Secretary of State
