Provider Demographics
NPI:1871601542
Name:SAMUEL J RUSSO DO PC
Entity type:Organization
Organization Name:SAMUEL J RUSSO DO PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:RUSSO
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:541-677-6586
Mailing Address - Street 1:2460 NW STEWART PKWY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97471-1516
Mailing Address - Country:US
Mailing Address - Phone:541-677-6586
Mailing Address - Fax:541-677-6509
Practice Address - Street 1:2460 NW STEWART PKWY
Practice Address - Street 2:SUITE 100
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97471-1516
Practice Address - Country:US
Practice Address - Phone:541-677-6586
Practice Address - Fax:541-677-6509
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-25
Last Update Date:2008-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR113090Medicare PIN