Provider Demographics
NPI:1265545271
Name:KUZNETSOVA, MARINA A (MD)
Entity type:Individual
Prefix:
First Name:MARINA
Middle Name:A
Last Name:KUZNETSOVA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 85327
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60689-5327
Mailing Address - Country:US
Mailing Address - Phone:814-237-8627
Mailing Address - Fax:
Practice Address - Street 1:100 PROVENA WAY STE 103
Practice Address - Street 2:
Practice Address - City:BOURBONNAIS
Practice Address - State:IL
Practice Address - Zip Code:60914-4797
Practice Address - Country:US
Practice Address - Phone:773-564-5070
Practice Address - Fax:773-564-5071
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-16
Last Update Date:2024-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360905952085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01632270OtherBLUE CROSS BLUE SHIELD IL
IL036090575Medicaid
ILG70014Medicare UPIN
IL036090575Medicaid