1427033927 NPI number — MARC S RUSSO M.D.

Table of content: MARC S RUSSO M.D. (NPI 1427033927)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427033927 NPI number — MARC S RUSSO M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RUSSO
Provider First Name:
MARC
Provider Middle Name:
S
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

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 Information

NPI Number:
1427033927
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/01/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
562 W 2ND AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LITITZ
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
17543-1816
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
717-626-2167
Provider Business Mailing Address Fax Number:
717-626-1915

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
562 W 2ND AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LITITZ
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
17543-1816
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
717-626-2167
Provider Business Practice Location Address Fax Number:
717-626-1915
Provider Enumeration Date:
12/07/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  MD042622L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 578413 . This is a "AETNA HMO" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: P002686 . This is a "GATEWAY HEALTH PLAN" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: G05182 . This is a "HEALTH ASSURANCE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 02110901 . This is a "CAPITAL BLUE CROSS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 36691 S1QG . This is a "GEISINGER HEALTH PLAN" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 5487080 . This is a "AETNA NON-HMO" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 775158 . This is a "HIGHMARK BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0015140170004 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0015140170001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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