Basic Information
| Provider Information | |||||||||
| NPI: | 1174664858 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | RUSSO | ||||||||
| FirstName: | ROCCO | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2570 ROUTE 9W STE 10 | ||||||||
| Address2: | |||||||||
| City: | CORNWALL | ||||||||
| State: | NY | ||||||||
| PostalCode: | 125181370 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8452203100 | ||||||||
| FaxNumber: | 8455342940 | ||||||||
| Practice Location | |||||||||
| Address1: | 127 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | HIGHLAND FALLS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 109284019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8454464076 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2007 | ||||||||
| LastUpdateDate: | 12/10/2018 | ||||||||
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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 | 207Q00000X | 035913 | CT | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 259143 | NY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 010035913CT | 01 | CT | ANTHEM | OTHER | 03421327 | 05 | NY | MEDICAID | 1174664858 | 05 | CT | MEDICAID | 2V9661 | 01 | CT | HEALTHNET | OTHER |