MEDICARE: DR. RICHARD F RUSSO MD

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	75640	FL

Other Identifiers

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

General Provider Information

NPI Number	:	1356425037
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RICHARD F RUSSO MD

Provider Business Mailing Address
First Line	:	PO BOX 95590
Second Line	:
City	:	SOUTH JORDAN
State	:	UT
Zip	:	84095-0590
Country	:	US
Telephone Number	:	801-352-9500
Fax Number	:

Provider Business Practice Location Address
First Line	:	5100 N 12TH AVE STE 101
Second Line	:
City	:	PENSACOLA
State	:	FL
Zip	:	32504-8919
Country	:	US
Telephone Number	:	850-208-6160
Fax Number	:

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

Provider Enumeration Date	:	10/25/2006
Last Update Date	:	03/23/2026

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