Healthcare Provider Details

I. General information

NPI: 1144213455
Provider Name (Legal Business Name): ANTHONY LEONARD RUSSO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2005
Last Update Date: 11/04/2021
Certification Date: 11/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 N SYRINGA ST STE 100
POST FALLS ID
83854-5275
US

IV. Provider business mailing address

1593 E POLSTON AVE
POST FALLS ID
83854-5326
US

V. Phone/Fax

Practice location:
  • Phone: 208-262-2600
  • Fax: 208-262-2700
Mailing address:
  • Phone: 208-262-2300
  • Fax: 208-262-2390

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberMD61084253
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberM-8310
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: