Provider Demographics
NPI:1659777530
Name:ANTONIO MARRA
Entity Type:Organization
Organization Name:ANTONIO MARRA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTONIO
Authorized Official - Middle Name:
Authorized Official - Last Name:MARRA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-755-4401
Mailing Address - Street 1:30 E 15TH ST STE 205
Mailing Address - Street 2:
Mailing Address - City:CHICAGO HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60411-3476
Mailing Address - Country:US
Mailing Address - Phone:708-755-4401
Mailing Address - Fax:
Practice Address - Street 1:30 E 15TH ST STE 205
Practice Address - Street 2:
Practice Address - City:CHICAGO HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60411-3476
Practice Address - Country:US
Practice Address - Phone:708-755-4401
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-05
Last Update Date:2014-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036038919261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care