Provider Demographics
NPI:1518926450
Name:LARSEN, MARIANNE B (MD)
Entity Type:Individual
Prefix:
First Name:MARIANNE
Middle Name:B
Last Name:LARSEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2300 CHILDRENS PLAZA
Mailing Address - Street 2:BOX 51
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614
Mailing Address - Country:US
Mailing Address - Phone:773-880-4352
Mailing Address - Fax:773-880-3374
Practice Address - Street 1:2300 CHILDRENS PLAZA
Practice Address - Street 2:BOX 51
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614
Practice Address - Country:US
Practice Address - Phone:773-880-4352
Practice Address - Fax:773-880-3374
Is Sole Proprietor?:No
Enumeration Date:2006-03-20
Last Update Date:2011-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360420652084N0402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036042065Medicaid
D12232Medicare UPIN
IL036042065Medicaid