Basic Information
| Provider Information | |||||||||
| NPI: | 1851478796 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RUSSO | ||||||||
| FirstName: | CAROLYN | ||||||||
| MiddleName: | L. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 910 ADAMS ST SE | ||||||||
| Address2: | SUITE 310 | ||||||||
| City: | HUNTSVILLE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 358013730 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2562655833 | ||||||||
| FaxNumber: | 2562655834 | ||||||||
| Practice Location | |||||||||
| Address1: | 910 ADAMS ST SE | ||||||||
| Address2: | SUITE 310 | ||||||||
| City: | HUNTSVILLE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 358013730 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2562655833 | ||||||||
| FaxNumber: | 2562655834 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2006 | ||||||||
| LastUpdateDate: | 01/30/2010 | ||||||||
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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 | 2080P0207X | G55159 | CA | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Hematology-Oncology |
ID Information
| ID | Type | State | Issuer | Description | 00G551590 | 05 | CA | MEDICAID |