Healthcare Provider Details

I. General information

NPI: 1205034519
Provider Name (Legal Business Name): MELISSA LAUREN RUSSO M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2007
Last Update Date: 07/12/2024
Certification Date: 07/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 PLAIN ST FL 6
PROVIDENCE RI
02903-4829
US

IV. Provider business mailing address

101 DUDLEY ST
PROVIDENCE RI
02905-2499
US

V. Phone/Fax

Practice location:
  • Phone: 401-274-1122
  • Fax: 401-453-7622
Mailing address:
  • Phone: 401-274-1122
  • Fax: 401-453-7622

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberMD15891
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code207VM0101X
TaxonomyMaternal & Fetal Medicine Physician
License Number274564
License Number StateMA
# 3
Primary TaxonomyY
Taxonomy Code207VM0101X
TaxonomyMaternal & Fetal Medicine Physician
License NumberMD15891
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: