Healthcare Provider Details

I. General information

NPI: 1598317232
Provider Name (Legal Business Name): KENNETH QUINLAN PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2019
Last Update Date: 01/25/2022
Certification Date: 01/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5501 OLD YORK RD STE 1
PHILADELPHIA PA
19141-3098
US

IV. Provider business mailing address

5145 N CALIFORNIA AVE
CHICAGO IL
60625-3661
US

V. Phone/Fax

Practice location:
  • Phone: 800-346-7834
  • Fax:
Mailing address:
  • Phone: 773-989-3800
  • Fax: 773-907-1005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberMA060646
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085008100
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: