=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326238585
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARIE MYRLANDE KERNIZAN M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/25/2007
-----------------------------------------------------
Last Update Date | 08/03/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9625 S COLFAX AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60617-4900
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-483-8400
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8349 S BALTIMORE AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60617-2110
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-978-5291
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number | 036099858
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------