Healthcare Provider Details

I. General information

NPI: 1053514513
Provider Name (Legal Business Name): QINWEN MAO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2007
Last Update Date: 11/20/2021
Certification Date: 11/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

710 N FAIRBANKS CT STE 2-458
CHICAGO IL
60611-3013
US

IV. Provider business mailing address

710 N FAIRBANKS CT STE 2-458
CHICAGO IL
60611-3013
US

V. Phone/Fax

Practice location:
  • Phone: 214-590-8058
  • Fax:
Mailing address:
  • Phone: 312-926-9487
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZN0500X
TaxonomyNeuropathology Physician
License Number036125842
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number036125842
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: