Healthcare Provider Details

I. General information

NPI: 1851040919
Provider Name (Legal Business Name): ANTHONY ROBERT RUSSO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/23/2022
Last Update Date: 06/10/2026
Certification Date: 06/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 FRUIT ST
BOSTON MA
02114-2696
US

IV. Provider business mailing address

51 PHILLIPS ST APT 10
BOSTON MA
02114-3657
US

V. Phone/Fax

Practice location:
  • Phone: 617-726-2000
  • Fax:
Mailing address:
  • Phone: 631-793-8174
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number1025979
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: