Healthcare Provider Details

I. General information

NPI: 1376296350
Provider Name (Legal Business Name): MARAT KUCHERINA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2022
Last Update Date: 05/16/2023
Certification Date: 05/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1438 W BELMONT AVE STE 1
CHICAGO IL
60657-2166
US

IV. Provider business mailing address

1438 W BELMONT AVE STE 1
CHICAGO IL
60657-2166
US

V. Phone/Fax

Practice location:
  • Phone: 312-508-3645
  • Fax: 312-971-8554
Mailing address:
  • Phone: 312-508-3645
  • Fax: 312-971-8554

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: