Healthcare Provider Details

I. General information

NPI: 1376510594
Provider Name (Legal Business Name): RALPH E RUSSO III M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2006
Last Update Date: 10/10/2024
Certification Date: 10/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

728 MARNE HWY STE 200A
MOORESTOWN NJ
08057-3128
US

IV. Provider business mailing address

301 LIPPINCOTT DR STE 410
MARLTON NJ
08053-4197
US

V. Phone/Fax

Practice location:
  • Phone: 856-291-8855
  • Fax: 856-291-5526
Mailing address:
  • Phone: 856-355-0340
  • Fax: 856-355-0330

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number25MA05172300
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code207UN0901X
TaxonomyNuclear Cardiology Physician
License Number25MA05172300
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: