Provider Demographics
NPI:1326238585
Name:KERNIZAN, MARIE MYRLANDE (MD)
Entity Type:Individual
Prefix:DR
First Name:MARIE
Middle Name:MYRLANDE
Last Name:KERNIZAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8349 S BALTIMORE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60617-2110
Mailing Address - Country:US
Mailing Address - Phone:773-978-5291
Mailing Address - Fax:
Practice Address - Street 1:9625 S COLFAX AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60617-4900
Practice Address - Country:US
Practice Address - Phone:773-483-8400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-25
Last Update Date:2007-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036099858208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice