Healthcare Provider Details

I. General information

NPI: 1679623615
Provider Name (Legal Business Name): KENAN QIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2007
Last Update Date: 05/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1160 JOLIET ST SUITE 103
DYER IN
46311-2096
US

IV. Provider business mailing address

1160 JOLIET ST SUITE 103
DYER IN
46311-2096
US

V. Phone/Fax

Practice location:
  • Phone: 219-322-8534
  • Fax: 219-865-9072
Mailing address:
  • Phone: 219-322-8534
  • Fax: 219-865-9072

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number01071421A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code2080P0205X
TaxonomyPediatric Endocrinology Physician
License Number01071421A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: