Healthcare Provider Details

I. General information

NPI: 1740630938
Provider Name (Legal Business Name): RICHARD WILLIAM RUSSILLO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2016
Last Update Date: 04/18/2025
Certification Date: 04/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1550 BOYSON RD
HIAWATHA IA
52233-2362
US

IV. Provider business mailing address

1550 BOYSON RD
HIAWATHA IA
52233-2362
US

V. Phone/Fax

Practice location:
  • Phone: 319-743-7300
  • Fax: 319-743-7311
Mailing address:
  • Phone: 319-743-7300
  • Fax: 319-743-7311

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberMD-47149
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code207LA0401X
TaxonomyAddiction Medicine (Anesthesiology) Physician
License NumberR-10612
License Number StateIA
# 3
Primary TaxonomyN
Taxonomy Code207LC0200X
TaxonomyCritical Care Medicine (Anesthesiology) Physician
License NumberR-10612
License Number StateIA
# 4
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberR-10612
License Number StateIA
# 5
Primary TaxonomyN
Taxonomy Code207LP3000X
TaxonomyPediatric Anesthesiology Physician
License NumberR-10612
License Number StateIA
# 6
Primary TaxonomyN
Taxonomy Code207LH0002X
TaxonomyHospice and Palliative Medicine (Anesthesiology) Physician
License NumberR-10612
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: