1245243112 NPI number — DR. ELLAMARIE B RUSSO-DEMARA D.O.

Table of content: DR. ELLAMARIE B RUSSO-DEMARA D.O. (NPI 1245243112)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245243112 NPI number — DR. ELLAMARIE B RUSSO-DEMARA D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RUSSO-DEMARA
Provider First Name:
ELLAMARIE
Provider Middle Name:
B
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
F

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:
1245243112
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/16/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 37
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SHARON
Provider Business Mailing Address State Name:
VT
Provider Business Mailing Address Postal Code:
05065
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
609-218-9447
Provider Business Mailing Address Fax Number:
802-728-2394

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
220 TOM MILLER RD.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PLATTSBURGH
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12901
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-562-2009
Provider Business Practice Location Address Fax Number:
518-561-2119
Provider Enumeration Date:
08/14/2006

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: 207V00000X , with the licence number:  0320000521 , registered in the state of VT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: VN3644 , issued by the state of ( VT ) . This identifiers is of the category "MEDICAID".




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