Healthcare Provider Details

I. General information

NPI: 1033442231
Provider Name (Legal Business Name): CHRISTOPHER ROSS RUSSO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2009
Last Update Date: 04/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

710 KENMOOR AVE SE SUITE 200
GRAND RAPIDS MI
49546-2379
US

IV. Provider business mailing address

710 KENMOOR AVE SE SUITE 200
GRAND RAPIDS MI
49546-2379
US

V. Phone/Fax

Practice location:
  • Phone: 616-588-7246
  • Fax: 616-588-7086
Mailing address:
  • Phone: 616-588-7246
  • Fax: 616-588-7086

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number4301064161
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number4301064161
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: