Provider Demographics
NPI:1174510978
Name:RUSSO, MARINA K (MD)
Entity Type:Individual
Prefix:
First Name:MARINA
Middle Name:K
Last Name:RUSSO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1118 LEGACY POINTE DR
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62711
Mailing Address - Country:US
Mailing Address - Phone:217-787-8870
Mailing Address - Fax:217-787-6158
Practice Address - Street 1:1118 LEGACY POINTE DR
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62711
Practice Address - Country:US
Practice Address - Phone:217-787-8870
Practice Address - Fax:217-787-6158
Is Sole Proprietor?:No
Enumeration Date:2005-10-05
Last Update Date:2022-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036102799207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL6394POtherCATERPILLAR
IL036102799Medicaid
IL14D0949277OtherCLIA CERT
IL08421024OtherBLUE CROSS BLUE SHIELD
IL020057300OtherBLACK LUNG
ILCD7143OtherRR MEDICARE GRP
IL6394POtherCATERPILLAR