Individual
MARILYN M C LACROSSE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
M.D.
Contact information
Practice address
360 STATION DR, CRYSTAL LAKE, IL 60014
(815) 338-6600
(847) 802-7112
Mailing address
360 STATION DR, CRYSTAL LAKE, IL 60014-7978
(815) 338-6600
(815) 455-8044
Taxonomy
Speciality
Code
Description
License number
State
207P00000X
Emergency Medicine Physician
036119800
IL
207P00000X
Emergency Medicine Physician
44165-020
WI
207Q00000X
Family Medicine Physician
Primary
036119800
IL
2080A0000X
Pediatric Adolescent Medicine Physician
036-119800
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
036119800
STATE LICENSE
IL
05
—
34182500
—
WI
01
—
930116115
MEDICARE RAILROAD
WI
01
—
930123614
MEDICARE RAILROAD
WI
01
—
P00226727
MEDICARE RAILROAD
WI
Enumeration date
06/18/2006
Last updated
06/07/2018
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