Healthcare Provider Details

I. General information

NPI: 1356719652
Provider Name (Legal Business Name): MATTHEW RUSSO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/03/2015
Last Update Date: 09/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 W BROAD ST SUITE 506
BETHLEHEM PA
18018-5717
US

IV. Provider business mailing address

156 TURKEY RD
KEMPTON PA
19529-8734
US

V. Phone/Fax

Practice location:
  • Phone: 610-954-5810
  • Fax:
Mailing address:
  • Phone: 908-304-5738
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN619623
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: