Provider Demographics
NPI:1679623615
Name:QIN, KENAN (MD)
Entity type:Individual
Prefix:
First Name:KENAN
Middle Name:
Last Name:QIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1160 JOLIET ST
Mailing Address - Street 2:SUITE 103
Mailing Address - City:DYER
Mailing Address - State:IN
Mailing Address - Zip Code:46311-2096
Mailing Address - Country:US
Mailing Address - Phone:219-322-8534
Mailing Address - Fax:219-865-9072
Practice Address - Street 1:1160 JOLIET ST
Practice Address - Street 2:SUITE 103
Practice Address - City:DYER
Practice Address - State:IN
Practice Address - Zip Code:46311-2096
Practice Address - Country:US
Practice Address - Phone:219-322-8534
Practice Address - Fax:219-865-9072
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2015-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01071421A2080P0205X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080P0205XAllopathic & Osteopathic PhysiciansPediatricsPediatric Endocrinology
Provider Identifiers
StateIdentifier IDID TypeIssuer
32-0149967OtherGROUP TAX ID
IL036106209Medicaid