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NPI Code Detail

MEDICARE: DR. TANYA RUSSO DO

MEDICARE: DR. TANYA RUSSO DO
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1208000000XPediatrics Physician0574SC
2208000000XPediatrics Physician2015-02335NC

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1013906098
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. TANYA RUSSO DO
Provider Business Mailing Address
First Line : PO BOX 601888
Second Line :
City : CHARLOTTE
State : NC
Zip : 28260-1888
Country : US
Telephone Number : 704-982-2683
Fax Number : 704-512-4808
Provider Business Practice Location Address
First Line : 105 YADKIN ST
Second Line : SUITE 303
City : ALBEMARLE
State : NC
Zip : 28001-3449
Country : US
Telephone Number : 803-532-2208
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 10/21/2005
Last Update Date : 02/02/2017

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