Provider Demographics
NPI:1427378413
Name:CONTE-RUSSIAN, MARC JOSEF (DO)
Entity Type:Individual
Prefix:DR
First Name:MARC
Middle Name:JOSEF
Last Name:CONTE-RUSSIAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 N. WINFIELD ROAD
Mailing Address - Street 2:SUITE 419
Mailing Address - City:WINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60190
Mailing Address - Country:US
Mailing Address - Phone:630-653-0848
Mailing Address - Fax:630-653-0988
Practice Address - Street 1:25 N. WINFIELD RD.
Practice Address - Street 2:SUITE 419
Practice Address - City:WINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60190
Practice Address - Country:US
Practice Address - Phone:630-653-0848
Practice Address - Fax:630-653-0988
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-02
Last Update Date:2015-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125.058327207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036131269Medicaid
IL920540OtherMEDICARE PTAN (GROUP)
ILF400149873OtherMEDICARE PTAN (INDIVIDUAL)