Provider Demographics
NPI:1134232135
Name:MARINA KUZNETSOVA MD SC
Entity type:Organization
Organization Name:MARINA KUZNETSOVA MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARINA
Authorized Official - Middle Name:
Authorized Official - Last Name:KUZNETSOVA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-564-5070
Mailing Address - Street 1:4646 N MARINE DR
Mailing Address - Street 2:RADIATION ONCOLOGY DEPARTMENT
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-5759
Mailing Address - Country:US
Mailing Address - Phone:773-564-5070
Mailing Address - Fax:773-564-5071
Practice Address - Street 1:4646 N MARINE DR
Practice Address - Street 2:RADIATION ONCOLOGY DEPARTMENT
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-5759
Practice Address - Country:US
Practice Address - Phone:773-564-5070
Practice Address - Fax:773-564-5071
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-16
Last Update Date:2007-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2085R0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0203XAllopathic & Osteopathic PhysiciansRadiologyTherapeutic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01632270OtherBLUE CROSS BLUE SHIELD IL
IL01632270OtherBLUE CROSS BLUE SHIELD IL
ILG70014Medicare UPIN