Basic Information
| Provider Information | |||||||||
| NPI: | 1861490195 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RUSSO | ||||||||
| FirstName: | PATRICK | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2555 COURT DR | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | GASTONIA | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280542134 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7048683256 | ||||||||
| FaxNumber: | 7048685870 | ||||||||
| Practice Location | |||||||||
| Address1: | 2555 COURT DR | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | GASTONIA | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280542134 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7048683256 | ||||||||
| FaxNumber: | 7048685870 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2005 | ||||||||
| LastUpdateDate: | 06/08/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 26794 | SC | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207UN0901X | 200301049 | NC | N | Allopathic & Osteopathic Physicians | Nuclear Medicine | Nuclear Cardiology | 207UN0901X | 26794 | SC | N | Allopathic & Osteopathic Physicians | Nuclear Medicine | Nuclear Cardiology | 207RC0000X | 200301049 | NC | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 891345R | 05 | NC | MEDICAID | N01046 | 05 | SC | MEDICAID |