Provider Demographics
NPI:1366510927
Name:KISELEV, MARIANNA (MD)
Entity type:Individual
Prefix:
First Name:MARIANNA
Middle Name:
Last Name:KISELEV
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8000
Mailing Address - Street 2:DEPT. 601
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14267-0002
Mailing Address - Country:US
Mailing Address - Phone:866-295-0041
Mailing Address - Fax:708-342-2517
Practice Address - Street 1:300 2ND AVE
Practice Address - Street 2:
Practice Address - City:LONG BRANCH
Practice Address - State:NJ
Practice Address - Zip Code:07740-6303
Practice Address - Country:US
Practice Address - Phone:732-923-6900
Practice Address - Fax:732-923-6914
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2011-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA70880002084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8315108Medicaid
NJ043373Medicare ID - Type Unspecified
NJH27511Medicare UPIN