Healthcare Provider Details

I. General information

NPI: 1265545271
Provider Name (Legal Business Name): MARINA A KUZNETSOVA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/16/2006
Last Update Date: 09/11/2024
Certification Date: 09/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 PROVENA WAY STE 103
BOURBONNAIS IL
60914-4797
US

IV. Provider business mailing address

PO BOX 85327
CHICAGO IL
60689-5327
US

V. Phone/Fax

Practice location:
  • Phone: 773-564-5070
  • Fax: 773-564-5071
Mailing address:
  • Phone: 814-237-8627
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number036090595
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: