Individual
MARINA K RUSSO
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
MD
Contact information
Practice address
1118 LEGACY POINTE DR, SPRINGFIELD, IL 62711
(217) 787-8870
(217) 787-6158
Mailing address
1118 LEGACY POINTE DR, SPRINGFIELD, IL 62711
(217) 787-8870
(217) 787-6158
Taxonomy
Speciality
Code
Description
License number
State
207RE0101X
Endocrinology, Diabetes & Metabolism Physician
Primary
036102799
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
020057300
BLACK LUNG
IL
05
—
036102799
—
IL
01
—
08421024
BLUE CROSS BLUE SHIELD
IL
01
—
14D0949277
CLIA CERT
IL
01
—
6394P
CATERPILLAR
IL
01
—
CD7143
RR MEDICARE GRP
IL
Enumeration date
10/05/2005
Last updated
01/04/2022
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