Healthcare Provider Details

I. General information

NPI: 1528072139
Provider Name (Legal Business Name): CARMEN RUSSO CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

435 HURFFVILLE - CROSS KEYS RD KENNEDY HEALTH SYSTEM
TURNERSVILLE NJ
08012
US

IV. Provider business mailing address

700 US 130 N SUITE 203
CINNAMINSON NJ
08077
US

V. Phone/Fax

Practice location:
  • Phone: 856-582-2500
  • Fax:
Mailing address:
  • Phone: 856-829-9345
  • Fax: 856-829-0580

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number26NR06658900
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: