Healthcare Provider Details

I. General information

NPI: 1134393267
Provider Name (Legal Business Name): KRISTINA MARIE POTANOS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2008
Last Update Date: 07/01/2024
Certification Date: 07/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 S PARK AVE FL 3
HERRIN IL
62948-3602
US

IV. Provider business mailing address

PO BOX 3988
CARBONDALE IL
62902-3988
US

V. Phone/Fax

Practice location:
  • Phone: 618-942-2002
  • Fax: 618-351-6497
Mailing address:
  • Phone: 618-457-5200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number036141342
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: