Healthcare Provider Details

I. General information

NPI: 1083609184
Provider Name (Legal Business Name): KENT S QUINN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2005
Last Update Date: 07/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 GOOD SAMARITAN WAY ATTN RADIOLOGY DEPT
MOUNT VERNON IL
62864-2402
US

IV. Provider business mailing address

PO BOX 66971 DEPT MR
SAINT LOUIS MO
63166-6971
US

V. Phone/Fax

Practice location:
  • Phone: 618-242-4600
  • Fax: 618-242-4600
Mailing address:
  • Phone: 303-465-0401
  • Fax: 303-438-1351

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License Number21181
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: