Basic Information
| Provider Information | |||||||||
| NPI: | 1417912973 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | QUINN | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 109 BEE ST | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294015703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8435775011 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 109 BEE ST | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294015703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8435775011 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2006 | ||||||||
| LastUpdateDate: | 02/13/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085B0100X | 11458 | NH | N | Allopathic & Osteopathic Physicians | Radiology | Body Imaging | 2085R0202X | 11458 | NH | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 30201769 | 05 | NH | MEDICAID | 01Y003557NH02 | 01 | NH | BLUE CROSS | OTHER | 01Y003557 NH05 | 01 | NH | ANTHEM MCH TAX ID | OTHER | 300123698 | 01 | NH | RAILROAD MEDICARE | OTHER | 011458 | 01 | NH | TUFTS | OTHER | 2675858 | 01 | NH | AETNA | OTHER | 294668 | 01 | NH | CIGNA | OTHER |