Healthcare Provider Details

I. General information

NPI: 1437129343
Provider Name (Legal Business Name): KENNETH J RUSSO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2006
Last Update Date: 12/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9097 E DESERT COVE DR STE 260
SCOTTSDALE AZ
85260-6278
US

IV. Provider business mailing address

9097 E DESERT COVE # 260
SCOTTSDALE AZ
85260
US

V. Phone/Fax

Practice location:
  • Phone: 480-684-1080
  • Fax:
Mailing address:
  • Phone: 480-684-1080
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number12608
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: