Healthcare Provider Details

I. General information

NPI: 1174510978
Provider Name (Legal Business Name): MARINA K RUSSO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2005
Last Update Date: 01/04/2022
Certification Date: 01/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1118 LEGACY POINTE DR
SPRINGFIELD IL
62711
US

IV. Provider business mailing address

1118 LEGACY POINTE DR
SPRINGFIELD IL
62711
US

V. Phone/Fax

Practice location:
  • Phone: 217-787-8870
  • Fax: 217-787-6158
Mailing address:
  • Phone: 217-787-8870
  • Fax: 217-787-6158

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number036102799
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: