Basic Information
| Provider Information | |||||||||
| NPI: | 1649302613 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VINCENT J. RUSSO, M.D., LTD. | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 10290 N 92ND ST | ||||||||
| Address2: | STE 103 | ||||||||
| City: | SCOTTSDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852584522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4808601322 | ||||||||
| FaxNumber: | 4808604062 | ||||||||
| Practice Location | |||||||||
| Address1: | 10290 N 92ND ST | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | SCOTTSDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852584522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4808601322 | ||||||||
| FaxNumber: | 4808604062 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/12/2007 | ||||||||
| LastUpdateDate: | 05/06/2008 | ||||||||
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| AuthorizedOfficialLastName: | RUSSO | ||||||||
| AuthorizedOfficialFirstName: | VINCENT | ||||||||
| AuthorizedOfficialMiddleName: | JOSEPH | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 4808601322 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 12496 | AZ | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.