Healthcare Provider Details

I. General information

NPI: 1295521235
Provider Name (Legal Business Name): RUSSOM PSYCHIATRY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/16/2025
Last Update Date: 04/16/2025
Certification Date: 04/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 W 29TH ST APT 3E
NEW YORK NY
10001-0106
US

IV. Provider business mailing address

50 W 29TH ST APT 3E
NEW YORK NY
10001-0106
US

V. Phone/Fax

Practice location:
  • Phone: 626-419-1178
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ELSA RUSSOM
Title or Position: MD
Credential:
Phone: 626-419-1178