MEDICARE: MR. SAM DOMINICK RUSSO MPAS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant

General Provider Information

NPI Number	:	1164823787
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. SAM DOMINICK RUSSO MPAS

Provider Business Mailing Address
First Line	:	3632 WILDWOOD ST
Second Line	:
City	:	YORKTOWN HEIGHTS
State	:	NY
Zip	:	10598-1129
Country	:	US
Telephone Number	:	914-582-8342
Fax Number	:	914-245-1394

Provider Business Practice Location Address
First Line	:	650 W 168TH ST
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10032-3702
Country	:	US
Telephone Number	:	212-305-7367
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/15/2014
Last Update Date	:	09/15/2014

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