MEDICARE: DR. ANGELA RUSSO AU.D.

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	231H00000X	Audiologist	AT006492	PA

General Provider Information

NPI Number	:	1447795810
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ANGELA RUSSO AU.D.

Provider Business Mailing Address
First Line	:	6301 WETZEL AVE
Second Line	:
City	:	FORT CARSON
State	:	CO
Zip	:	80913-4188
Country	:	US
Telephone Number	:	719-526-4095
Fax Number	:

Provider Business Practice Location Address
First Line	:	6301 WETZEL AVE
Second Line	:	BLDG 1525
City	:	FORT CARSON
State	:	CO
Zip	:	80913-4188
Country	:	US
Telephone Number	:	719-526-4095
Fax Number	:

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

Provider Enumeration Date	:	12/21/2016
Last Update Date	:	12/21/2016

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