Healthcare Provider Details

I. General information

NPI: 1164402707
Provider Name (Legal Business Name): ANTHONY JOHN RUSSO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/19/2006
Last Update Date: 11/06/2024
Certification Date: 11/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 25TH ST S
GREAT FALLS MT
59405-5183
US

IV. Provider business mailing address

PO BOX 6010
GREAT FALLS MT
59406-6010
US

V. Phone/Fax

Practice location:
  • Phone: 406-455-5000
  • Fax:
Mailing address:
  • Phone: 406-455-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number11747
License Number StateMT
# 2
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberMD00045946
License Number StateWA
# 3
Primary TaxonomyY
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number11747
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: