Healthcare Provider Details

I. General information

NPI: 1891785051
Provider Name (Legal Business Name): RUSSELL ROTONDO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/27/2005
Last Update Date: 01/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7557B DANNAHER DR STE 225
POWELL TN
37849-3568
US

IV. Provider business mailing address

7557B DANNAHER DR STE 225
POWELL TN
37849-3568
US

V. Phone/Fax

Practice location:
  • Phone: 865-647-5800
  • Fax: 865-647-5979
Mailing address:
  • Phone: 865-647-5800
  • Fax: 865-647-5979

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number21440
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: