Basic Information
| Provider Information | |||||||||
| NPI: | 1144213455 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RUSSO | ||||||||
| FirstName: | ANTHONY | ||||||||
| MiddleName: | LEONARD | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1593 E POLSTON AVE | ||||||||
| Address2: | |||||||||
| City: | POST FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838545326 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082622300 | ||||||||
| FaxNumber: | 2082622390 | ||||||||
| Practice Location | |||||||||
| Address1: | 750 N SYRINGA ST STE 100 | ||||||||
| Address2: | |||||||||
| City: | POST FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838545275 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082622600 | ||||||||
| FaxNumber: | 2082622700 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2005 | ||||||||
| LastUpdateDate: | 11/04/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | MD61084253 | WA | N | Allopathic & Osteopathic Physicians | General Practice | 207P00000X | M-8310 | ID | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1144213455 | 05 | ID | MEDICAID | 2106800 | 05 | WA | MEDICAID |