Healthcare Provider Details

I. General information

NPI: 1609836907
Provider Name (Legal Business Name): RUSSELL S BUFALINO M.D.,J.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/23/2006
Last Update Date: 03/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

313 S MAIN ST
OLD FORGE PA
18518-1606
US

IV. Provider business mailing address

313 S MAIN ST
OLD FORGE PA
18518-1606
US

V. Phone/Fax

Practice location:
  • Phone: 570-451-1122
  • Fax: 570-451-0541
Mailing address:
  • Phone: 570-451-1122
  • Fax: 570-451-0541

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Z00000X
TaxonomyOrthotist
License NumberMD008940E
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier7289228
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerAETNA
# 2
Identifier1563559
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer
# 3
IdentifierBU108435
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerBLUE CROSS BLUE SHIELD
# 4
Identifier817264
Identifier TypeOTHER
Identifier StatePA
Identifier Issuer1ST PRIORITY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: