MEDICARE: DR. RUSSELL J CAVALLO M.D.

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
1	207XX0005X	Sports Medicine (Orthopaedic Surgery) Physician	196211	NY
2	207XX0005X	Sports Medicine (Orthopaedic Surgery) Physician	038069	CT

General Provider Information

NPI Number	:	1023011327
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RUSSELL J CAVALLO M.D.

Provider Business Mailing Address
First Line	:	90 S RIDGE ST
Second Line	:	SUITE UL-1
City	:	RYE BROOK
State	:	NY
Zip	:	10573-2867
Country	:	US
Telephone Number	:	914-708-1111
Fax Number	:

Provider Business Practice Location Address
First Line	:	90 S RIDGE ST
Second Line	:	SUITE UL-1
City	:	RYE BROOK
State	:	NY
Zip	:	10573-2867
Country	:	US
Telephone Number	:	914-708-1111
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/31/2005
Last Update Date	:	10/04/2011

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