MEDICARE: SIMONE FRANK RUSSO

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	207Q00000X	Family Medicine Physician	4511	NV

General Provider Information

NPI Number	:	1134294259
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SIMONE FRANK RUSSO

Provider Business Mailing Address
First Line	:	2428 SABADO ST
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89121-4125
Country	:	US
Telephone Number	:	702-792-4077
Fax Number	:	702-991-8044

Provider Business Practice Location Address
First Line	:	2900 E DESERT INN RD
Second Line	:	SUITE 108
City	:	LAS VEGAS
State	:	NV
Zip	:	89121-3619
Country	:	US
Telephone Number	:	702-369-2628
Fax Number	:	702-792-4328

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

Provider Enumeration Date	:	11/22/2006
Last Update Date	:	07/08/2007

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Directions to “ SIMONE FRANK RUSSO ” Practice Location

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