1467466656 NPI number — DR. KELLY SIPE RUSSO M.D., M.P.H.

Table of content: DR. KELLY SIPE RUSSO M.D., M.P.H. (NPI 1467466656)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467466656 NPI number — DR. KELLY SIPE RUSSO M.D., M.P.H.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RUSSO
Provider First Name:
KELLY
Provider Middle Name:
SIPE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D., M.P.H.
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:
1467466656
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/12/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1 HARRY TRUMAN PARKWAY
Provider Second Line Business Mailing Address:
MS 3102
Provider Business Mailing Address City Name:
ANNAPOLIS
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21401
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-222-4114
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1 HARRY S TRUMAN PKWY
Provider Second Line Business Practice Location Address:
MS 3102
Provider Business Practice Location Address City Name:
ANNAPOLIS
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21401-7037
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-222-4114
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/27/2006

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: 207RI0200X , with the licence number:  D0061987 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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