Healthcare Provider Details

I. General information

NPI: 1710128699
Provider Name (Legal Business Name): GARY E RUSSOLILLO MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/23/2009
Last Update Date: 03/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

970 FARMINGTON AVE
WEST HARTFORD CT
06107-2139
US

IV. Provider business mailing address

970 FARMINGTON AVE
WEST HARTFORD CT
06107-2139
US

V. Phone/Fax

Practice location:
  • Phone: 860-521-2200
  • Fax: 860-521-2605
Mailing address:
  • Phone: 860-521-2200
  • Fax: 860-521-2605

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. GARY EDWARD RUSSOLILLO
Title or Position: PRESIDENT
Credential: MD
Phone: 860-521-2200