Basic Information
| Provider Information | |||||||||
| NPI: | 1811072994 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RUSSO | ||||||||
| FirstName: | EILEEN | ||||||||
| MiddleName: | SUSAN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 254 EASTON AVE | ||||||||
| Address2: | SAINT PETER'S UNIVERSITY HOSPITAL | ||||||||
| City: | NEW BRUNSWICK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 089011766 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7327458600 | ||||||||
| FaxNumber: | 7327459156 | ||||||||
| Practice Location | |||||||||
| Address1: | 254 EASTON AVE | ||||||||
| Address2: | SAINT PETER'S UNIVERSITY HOSPITAL | ||||||||
| City: | NEW BRUNSWICK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 089011766 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7327458600 | ||||||||
| FaxNumber: | 7327459156 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RP1001X | 25MA07642600 | NJ | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
| ID | Type | State | Issuer | Description | 0011657 | 05 | NJ | MEDICAID |