Provider Demographics
NPI:1053862029
Name:MARINA RUSSMAN M.D., APC
Entity Type:Organization
Organization Name:MARINA RUSSMAN M.D., APC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:F
Authorized Official - Middle Name:MARINA
Authorized Official - Last Name:RUSSMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-273-2707
Mailing Address - Street 1:8306 WILSHIRE BLVD # 1808
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90211-2304
Mailing Address - Country:US
Mailing Address - Phone:310-273-2707
Mailing Address - Fax:310-273-2737
Practice Address - Street 1:250 N ROBERTSON BLVD STE 106
Practice Address - Street 2:
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90211-1767
Practice Address - Country:US
Practice Address - Phone:310-273-2707
Practice Address - Fax:310-273-2737
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-14
Last Update Date:2016-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE85715Medicare UPIN