MEDICARE: DR. RANDOLPH JOSEPH RUSSO DC

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	111N00000X	Chiropractor	X008265-1	NY

General Provider Information

NPI Number	:	1073697637
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RANDOLPH JOSEPH RUSSO DC

Provider Business Mailing Address
First Line	:	16 SQUADRON BLVD
Second Line	:	STE 102
City	:	NEW CITY
State	:	NY
Zip	:	10956-5268
Country	:	US
Telephone Number	:	845-634-2225
Fax Number	:	845-634-2227

Provider Business Practice Location Address
First Line	:	16 SQUADRON BLVD
Second Line	:	STE 102
City	:	NEW CITY
State	:	NY
Zip	:	10956-5268
Country	:	US
Telephone Number	:	845-634-2225
Fax Number	:	845-634-2227

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

Provider Enumeration Date	:	10/24/2006
Last Update Date	:	04/25/2023

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