MEDICARE: RENEE MARIE RUSSO

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	174400000X	Specialist

General Provider Information

NPI Number	:	1528372232
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RENEE MARIE RUSSO

Provider Business Mailing Address
First Line	:	3535 PORTILLO RD APT 10
Second Line	:
City	:	SPRING HILL
State	:	FL
Zip	:	34608-7274
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3535 PORTILLO RD APT 10
Second Line	:
City	:	SPRING HILL
State	:	FL
Zip	:	34608-7274
Country	:	US
Telephone Number	:	352-942-4723
Fax Number	:

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

Provider Enumeration Date	:	08/05/2010
Last Update Date	:	08/05/2010

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