1063437515 NPI number — SUZANNE M RUSSO MD

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063437515 NPI number — SUZANNE M RUSSO MD

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

RUSSO

Provider First Name:

SUZANNE

Provider Middle Name:

M

Provider Name Prefix Text:

Provider Name Suffix Text:

Provider Credential Text:

MD

Provider Gender Code:

F

Provider Other Organization Name:

Provider Other Organization Name Type Code:

Provider Other Last Name:

Provider Other First Name:

Provider Other Middle Name:

Provider Other Name Prefix Text:

Provider Other Name Suffix Text:

Provider Other Credential Text:

Provider Other Last Name Type Code:

NPI Number:

1063437515

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

12/01/2020

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

20800 HARVARD RD

Provider Second Line Business Mailing Address:

2ND FLOOR

Provider Business Mailing Address City Name:

HIGHLAND HILLS

Provider Business Mailing Address State Name:

OH

Provider Business Mailing Address Postal Code:

44122-7202

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

Provider Business Mailing Address Fax Number:

Provider First Line Business Practice Location Address:

11100 EUCLID AVE

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:

CLEVELAND

Provider Business Practice Location Address State Name:

OH

Provider Business Practice Location Address Postal Code:

44106-1716

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

216-844-3951

Provider Business Practice Location Address Fax Number:

Provider Enumeration Date:

07/13/2006

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 2085R0001X , with the licence number:  40280 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 2085R0001X , with the licence number: 24394 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 2085R0001X , with the licence number: 97-00385 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 2085R0001X , with the licence number: 19098 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 2085R0001X , with the licence number: 35.125723 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 0135692 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
• Identifier: 126MH . This is a "BCBS" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
• Identifier: 920006473 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
• Identifier: 89126MH , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
• Identifier: 051513420 . This is a "BLUE CROSS" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".