MEDICARE: QINWEN MAO MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207ZN0500X	Neuropathology Physician	036125842	IL
2	207ZP0102X	Anatomic Pathology & Clinical Pathology Physician	036125842	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	BP1-0022464	OTHER		INSTITUTIONAL PERMIT

General Provider Information

NPI Number	:	1053514513
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	QINWEN MAO MD

Provider Business Mailing Address
First Line	:	710 N FAIRBANKS CT STE 2-458
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60611-3013
Country	:	US
Telephone Number	:	312-926-9487
Fax Number	:

Provider Business Practice Location Address
First Line	:	710 N FAIRBANKS CT STE 2-458
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60611-3013
Country	:	US
Telephone Number	:	214-590-8058
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/11/2007
Last Update Date	:	11/20/2021

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Directions to “ QINWEN MAO MD” Practice Location

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