Provider Demographics
NPI:1669591509
Name:M .KUSHNER MD
Entity type:Organization
Organization Name:M .KUSHNER MD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARLA
Authorized Official - Middle Name:
Authorized Official - Last Name:KUSHNER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:773-244-9600
Mailing Address - Street 1:2437 N SOUTHPORT AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-2060
Mailing Address - Country:US
Mailing Address - Phone:773-244-9600
Mailing Address - Fax:773-248-2348
Practice Address - Street 1:2437 N SOUTHPORT AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-2060
Practice Address - Country:US
Practice Address - Phone:773-244-9600
Practice Address - Fax:773-248-2348
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL31603434OtherBCBS
IL781141Medicare ID - Type UnspecifiedMEDICARE
C40476Medicare UPIN