Provider Demographics
NPI:1689772956
Name:MARINOVIC, DEBRA (PA)
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:
Last Name:MARINOVIC
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:DEBRA
Other - Middle Name:
Other - Last Name:DIMARTINO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:630 S HERMITAGE AVE
Mailing Address - Street 2:SUITE 804
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-3874
Mailing Address - Country:US
Mailing Address - Phone:312-942-8925
Mailing Address - Fax:312-942-8288
Practice Address - Street 1:1725 W HARRISON ST
Practice Address - Street 2:SUITE 1010
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3841
Practice Address - Country:US
Practice Address - Phone:312-942-8925
Practice Address - Fax:312-942-8288
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2015-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085-002278363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant