Provider Demographics
NPI:1003897703
Name:QUIN, JACQUELYN A (MD)
Entity type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:A
Last Name:QUIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 VFW PKWY
Mailing Address - Street 2:MAIL CODE 112
Mailing Address - City:WEST ROXBURY
Mailing Address - State:MA
Mailing Address - Zip Code:02132-4927
Mailing Address - Country:US
Mailing Address - Phone:857-203-6202
Mailing Address - Fax:857-203-5757
Practice Address - Street 1:1400 VFW PKWY
Practice Address - Street 2:
Practice Address - City:WEST ROXBURY
Practice Address - State:MA
Practice Address - Zip Code:02132
Practice Address - Country:US
Practice Address - Phone:857-203-6202
Practice Address - Fax:857-203-5738
Is Sole Proprietor?:No
Enumeration Date:2005-11-09
Last Update Date:2018-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036105475208G00000X
CAG78462208G00000X
TXK9154208G00000X
MA207205208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036105475Medicaid
IL256510Medicare PIN
ILL88522Medicare PIN
H23594Medicare UPIN