Healthcare Provider Details

I. General information

NPI: 1083683445
Provider Name (Legal Business Name): GLENN GERARD RUSSO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2006
Last Update Date: 02/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 MEADOWCREST ST SUITE 160
GRETNA LA
70056-5255
US

IV. Provider business mailing address

600 OLIVE AVE
HARVEY LA
70058-4456
US

V. Phone/Fax

Practice location:
  • Phone: 504-391-7620
  • Fax: 504-391-7624
Mailing address:
  • Phone: 504-366-5035
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number017336
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: