Healthcare Provider Details

I. General information

NPI: 1154500585
Provider Name (Legal Business Name): MARINA N KORNEEVA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2007
Last Update Date: 12/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 CLINTON ST
WOONSOCKET RI
02895-3207
US

IV. Provider business mailing address

450 CLINTON ST
WOONSOCKET RI
02895-3207
US

V. Phone/Fax

Practice location:
  • Phone: 401-767-4100
  • Fax: 401-235-6899
Mailing address:
  • Phone: 401-767-4100
  • Fax: 401-235-6899

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number241685-1
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD12604
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: