Healthcare Provider Details

I. General information

NPI: 1952543811
Provider Name (Legal Business Name): RUSSELL R RUSSO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: DR. RUSSELL RUBEN RUSSO

II. Dates (important events)

Enumeration Date: 03/24/2009
Last Update Date: 03/25/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5620 READ BLVD
NEW ORLEANS LA
70127-3106
US

IV. Provider business mailing address

6901 CANAL BLVD
NEW ORLEANS LA
70124-3407
US

V. Phone/Fax

Practice location:
  • Phone: 504-592-6600
  • Fax: 504-592-6438
Mailing address:
  • Phone: 504-592-6437
  • Fax: 504-592-6438

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License NumberMD205273
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: