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General NPI Number Information
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NPI Number | 1508876236
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Entity Type | Individual
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Provider Name | MARTIN T RUSSO JR. DO
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Gender | Male
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Dates
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Enumeration Date | 08/08/2006
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Last Update Date | 06/11/2018
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Provider Practice Location Address
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Address Line | 1310 WISCONSIN AVE STE 103
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City | GRAND HAVEN
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State | MI
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Zip | 49417
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Country | US
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Telephone | 616-846-2640
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Fax | 616-846-3110
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Provider Business Mailing Address
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Address Line | 1310 WISCONSIN AVE STE 101
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City | GRAND HAVEN
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State | MI
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Zip | 49417-2472
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Country | US
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Telephone | 616-847-5604
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Fax | 616-846-0141
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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 | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 5101014183
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License Number State | MI
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