MEDICARE: PATRICK J RUSSO JR. 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	207RC0000X	Cardiovascular Disease Physician	26794	SC
2	207UN0901X	Nuclear Cardiology Physician	200301049	NC
3	207UN0901X	Nuclear Cardiology Physician	26794	SC
4	207RC0000X	Cardiovascular Disease Physician	200301049	NC

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	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1861490195
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PATRICK J RUSSO JR. MD

Provider Business Mailing Address
First Line	:	2555 COURT DR
Second Line	:	SUITE 200
City	:	GASTONIA
State	:	NC
Zip	:	28054-2134
Country	:	US
Telephone Number	:	704-868-3256
Fax Number	:	704-868-5870

Provider Business Practice Location Address
First Line	:	2555 COURT DR
Second Line	:	SUITE 300
City	:	GASTONIA
State	:	NC
Zip	:	28054-2134
Country	:	US
Telephone Number	:	704-868-3256
Fax Number	:	704-868-5870

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

Provider Enumeration Date	:	07/11/2005
Last Update Date	:	06/08/2017

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Directions to “ PATRICK J RUSSO JR. MD” Practice Location

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