MEDICARE: GREGORY K 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	2085R0202X	Diagnostic Radiology Physician	043621	CT
2	2085R0202X	Diagnostic Radiology Physician	112031	GA

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
2	010043621	OTHER	CT	ANTHEM BC/BS

General Provider Information

NPI Number	:	1770502361
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GREGORY K RUSSO MD

Provider Business Mailing Address
First Line	:	PO BOX 6128
Second Line	:	ROBERT D. RUSSO, M.D. & ASSOCIATES RADIOLOGY, P.C.
City	:	BRIDGEPORT
State	:	CT
Zip	:	06606-0128
Country	:	US
Telephone Number	:	203-683-4570
Fax Number	:	203-926-1415

Provider Business Practice Location Address
First Line	:	2909 MAIN ST
Second Line	:	ROBERT D. RUSSO, M.D. & ASSOCIATES RADIOLOGY, P.C.
City	:	STRATFORD
State	:	CT
Zip	:	06614-4960
Country	:	US
Telephone Number	:	203-683-4570
Fax Number	:	203-926-1415

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

Provider Enumeration Date	:	07/18/2006
Last Update Date	:	04/30/2026

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