Healthcare Provider Details

I. General information

NPI: 1093794356
Provider Name (Legal Business Name): RUSSELL L MAIESE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/13/2006
Last Update Date: 05/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 GREENWICH PL
SHELTON CT
06484-4618
US

IV. Provider business mailing address

14275 MIDWAY RD SUITE 400
ADDISON TX
75001-3614
US

V. Phone/Fax

Practice location:
  • Phone: 866-436-9631
  • Fax: 203-929-2344
Mailing address:
  • Phone: 866-436-9631
  • Fax: 610-271-4245

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZH0000X
TaxonomyHematology (Pathology) Physician
License Number036583
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number036583
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: