Provider Demographics
NPI:1255376885
Name:LACROSSE, MARILYN M C (MD)
Entity type:Individual
Prefix:
First Name:MARILYN
Middle Name:M C
Last Name:LACROSSE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARILYN
Other - Middle Name:M
Other - Last Name:CUENCA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:360 STATION DR
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60014-7978
Mailing Address - Country:US
Mailing Address - Phone:815-338-6600
Mailing Address - Fax:815-455-8044
Practice Address - Street 1:360 STATION DR
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014
Practice Address - Country:US
Practice Address - Phone:815-338-6600
Practice Address - Fax:847-802-7112
Is Sole Proprietor?:No
Enumeration Date:2006-06-18
Last Update Date:2018-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI44165-020207P00000X
IL036119800207P00000X, 207Q00000X
IL036-1198002080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34182500Medicaid
WI930116115OtherMEDICARE RAILROAD
IL036119800OtherSTATE LICENSE
WIP00226727OtherMEDICARE RAILROAD
WI930123614OtherMEDICARE RAILROAD
WI930123614OtherMEDICARE RAILROAD
G64301Medicare UPIN
WI0034-32280Medicare ID - Type Unspecified
WI0121-68655Medicare ID - Type Unspecified
WI930116115OtherMEDICARE RAILROAD