Provider Demographics
NPI:1447448246
Name:TIMOTHY C DELRUSSO MD PC
Entity type:Organization
Organization Name:TIMOTHY C DELRUSSO MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:CARL
Authorized Official - Last Name:DELRUSSO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:518-382-2077
Mailing Address - Street 1:1541 UNION ST
Mailing Address - Street 2:FIRST FLOOR
Mailing Address - City:SCHENECTADY
Mailing Address - State:NY
Mailing Address - Zip Code:12309-6001
Mailing Address - Country:US
Mailing Address - Phone:518-382-2077
Mailing Address - Fax:518-382-2077
Practice Address - Street 1:1541 UNION ST
Practice Address - Street 2:FIRST FLOOR
Practice Address - City:SCHENECTADY
Practice Address - State:NY
Practice Address - Zip Code:12309-6001
Practice Address - Country:US
Practice Address - Phone:518-382-2077
Practice Address - Fax:518-382-2077
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-05
Last Update Date:2007-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY165387-1174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY52178AMedicare PIN