MEDICARE: DR. STEFANI ANN RUSSO 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	207R00000X	Internal Medicine Physician	046659	CT
2	207R00000X	Internal Medicine Physician	259999	NY
3	207R00000X	Internal Medicine Physician	36913	SC
4	207R00000X	Internal Medicine Physician	MD456132	PA

General Provider Information

NPI Number	:	1588717177
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. STEFANI ANN RUSSO M.D.

Provider Business Mailing Address
First Line	:	700 WALNUT ST FL 2
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19106-3505
Country	:	US
Telephone Number	:	215-503-4779
Fax Number	:	215-503-4922

Provider Business Practice Location Address
First Line	:	700 WALNUT ST FL 2
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19106-3505
Country	:	US
Telephone Number	:	215-503-4779
Fax Number	:	215-503-4922

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

Provider Enumeration Date	:	01/19/2007
Last Update Date	:	09/21/2018

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