Provider Demographics
NPI:1972764041
Name:MARINA, SHADI (MD)
Entity type:Individual
Prefix:
First Name:SHADI
Middle Name:
Last Name:MARINA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6526 SPRING BROOK RD APT 306
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61114-8130
Mailing Address - Country:US
Mailing Address - Phone:847-708-5156
Mailing Address - Fax:
Practice Address - Street 1:1401 E STATE ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61104-2315
Practice Address - Country:US
Practice Address - Phone:815-968-4400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-21
Last Update Date:2009-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILFM1299038207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILJWA402M64951OtherBLUE CROSS BLUE SHIELD