Basic Information
Provider Information | |||||||||
NPI: | 1588661532 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | NUSYNOWITZ | ||||||||
FirstName: | RUSSELL | ||||||||
MiddleName: | N | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 621 ESTATES PL | ||||||||
Address2: |   | ||||||||
City: | LONGWOOD | ||||||||
State: | FL | ||||||||
PostalCode: | 327792857 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4074512069 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2120 LAKELAND HILLS BLVD | ||||||||
Address2: |   | ||||||||
City: | LAKELAND | ||||||||
State: | FL | ||||||||
PostalCode: | 338052906 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8636882334 | ||||||||
FaxNumber: | 8635771167 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/06/2005 | ||||||||
LastUpdateDate: | 02/03/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085B0100X | ME78190 | FL | N |   | Allopathic & Osteopathic Physicians | Radiology | Body Imaging | 2085R0202X | ME78190 | FL | Y |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
ID | Type | State | Issuer | Description | 256418100 | 05 | FL |   | MEDICAID | 46835 | 01 | FL | BCBS OF FLORIDA | OTHER | P00042108 | 01 | FL | RR MEDICARE | OTHER |