Basic Information
| Provider Information | |||||||||
| NPI: | 1255376885 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LACROSSE | ||||||||
| FirstName: | MARILYN | ||||||||
| MiddleName: | M C | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CUENCA | ||||||||
| OtherFirstName: | MARILYN | ||||||||
| OtherMiddleName: | M | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 360 STATION DR | ||||||||
| Address2: | |||||||||
| City: | CRYSTAL LAKE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600147978 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8153386600 | ||||||||
| FaxNumber: | 8154558044 | ||||||||
| Practice Location | |||||||||
| Address1: | 360 STATION DR | ||||||||
| Address2: | |||||||||
| City: | CRYSTAL LAKE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8153386600 | ||||||||
| FaxNumber: | 8478027112 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2006 | ||||||||
| LastUpdateDate: | 06/07/2018 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 44165-020 | WI | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 036119800 | IL | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 2080A0000X | 036-119800 | IL | N | Allopathic & Osteopathic Physicians | Pediatrics | Adolescent Medicine | 207Q00000X | 036119800 | IL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 34182500 | 05 | WI | MEDICAID | 930116115 | 01 | WI | MEDICARE RAILROAD | OTHER | 036119800 | 01 | IL | STATE LICENSE | OTHER | P00226727 | 01 | WI | MEDICARE RAILROAD | OTHER | 930123614 | 01 | WI | MEDICARE RAILROAD | OTHER |