MEDICARE: DANIEL JASON QUENNEVILLE M.D.

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	2085R0202X	Diagnostic Radiology Physician	35.080743	OH
2	2085R0202X	Diagnostic Radiology Physician	4301052746	MI
3	2085R0202X	Diagnostic Radiology Physician	36117436	IL
4	2085R0202X	Diagnostic Radiology Physician	3569	AK

General Provider Information

NPI Number	:	1740276500
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DANIEL JASON QUENNEVILLE M.D.

Provider Business Mailing Address
First Line	:	5643 WOODMANSEE WAY
Second Line	:
City	:	LIBERTY TWP
State	:	OH
Zip	:	45011-5914
Country	:	US
Telephone Number	:	937-241-1670
Fax Number	:

Provider Business Practice Location Address
First Line	:	5643 WOODMANSEE WAY
Second Line	:
City	:	LIBERTY TWP
State	:	OH
Zip	:	45011-5914
Country	:	US
Telephone Number	:	937-241-1670
Fax Number	:

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

Provider Enumeration Date	:	09/26/2005
Last Update Date	:	05/12/2020

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