Basic Information
| Provider Information | |||||||||
| NPI: | 1346298379 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RUSSO | ||||||||
| FirstName: | CHRISTOPHER | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 13579 | ||||||||
| Address2: | |||||||||
| City: | READING | ||||||||
| State: | PA | ||||||||
| PostalCode: | 196123579 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4846281324 | ||||||||
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| Practice Location | |||||||||
| Address1: | 160 E ERIE AVE | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191341011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2154275369 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2006 | ||||||||
| LastUpdateDate: | 11/08/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0204X | MD070605L | PA | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Emergency Medicine | 207PP0204X | C1000 | DE | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | Pediatric Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0018166710001 | 05 | PA | MEDICAID |