Basic Information
| Provider Information | |||||||||
| NPI: | 1114923893 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ORTHOPAEDIC SPECIALTY GROUP, P.C. | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | ROBERT D. RUSSO, M.D. & ASSOCIATES RADIOLOGY, P.C. | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 6128 | ||||||||
| Address2: | |||||||||
| City: | BRIDGEPORT | ||||||||
| State: | CT | ||||||||
| PostalCode: | 066060128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2035385233 | ||||||||
| FaxNumber: | 2035385246 | ||||||||
| Practice Location | |||||||||
| Address1: | 305 BLACK ROCK TPKE | ||||||||
| Address2: | |||||||||
| City: | FAIRFIELD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06825 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2033372600 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2005 | ||||||||
| LastUpdateDate: | 12/14/2018 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ORTIZ | ||||||||
| AuthorizedOfficialFirstName: | JUDITH | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 2035385233 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 016805 | CT | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 004107894 | 05 | CT | MEDICAID |