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General NPI Number Information
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NPI Number | 1013946417
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Entity Type | Individual
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Provider Name | MATTHEW JOHN RUSSO M.S., CCC-A
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Gender | Male
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Dates
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Enumeration Date | 06/30/2006
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Last Update Date | 01/14/2009
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Provider Practice Location Address
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Address Line | 7 ESSEX GREEN DR SUITE 2
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City | PEABODY
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State | MA
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Zip | 01960-2961
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Country | US
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Telephone | 978-532-6650
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 406153
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City | ATLANTA
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State | GA
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Zip | 30384-1876
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Country | US
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Telephone | 978-532-6650
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 231H00000X
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Taxonomy Name | Audiologist
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License Number | 777
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License Number State | MA
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