MEDICARE: MARINA K RUSSO MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RE0101X	Endocrinology, Diabetes & Metabolism Physician	036102799	IL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
6	CD7143	OTHER	IL	RR MEDICARE GRP

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	6394P	OTHER	IL	CATERPILLAR
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	14D0949277	OTHER	IL	CLIA CERT
4	08421024	OTHER	IL	BLUE CROSS BLUE SHIELD
5	020057300	OTHER	IL	BLACK LUNG

General Provider Information

NPI Number	:	1174510978
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARINA K RUSSO MD

Provider Business Mailing Address
First Line	:	1118 LEGACY POINTE DR
Second Line	:
City	:	SPRINGFIELD
State	:	IL
Zip	:	62711
Country	:	US
Telephone Number	:	217-787-8870
Fax Number	:	217-787-6158

Provider Business Practice Location Address
First Line	:	1118 LEGACY POINTE DR
Second Line	:
City	:	SPRINGFIELD
State	:	IL
Zip	:	62711
Country	:	US
Telephone Number	:	217-787-8870
Fax Number	:	217-787-6158

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/05/2005
Last Update Date	:	01/04/2022

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Directions to “ MARINA K RUSSO MD” Practice Location

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