Provider Demographics
NPI:1073676987
Name:MARINO, SUSANA G (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:SUSANA
Middle Name:G
Last Name:MARINO
Suffix:
Gender:F
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 14499
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-0499
Mailing Address - Country:US
Mailing Address - Phone:847-702-8782
Mailing Address - Fax:
Practice Address - Street 1:5841 S MARYLAND AVE
Practice Address - Street 2:MC 0006
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60637-1447
Practice Address - Country:US
Practice Address - Phone:773-702-1606
Practice Address - Fax:773-702-9082
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
064174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist