Provider Demographics
NPI:1871972232
Name:MICHAEL B RUSSO MD, INC
Entity type:Organization
Organization Name:MICHAEL B RUSSO MD, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:BRIAN
Authorized Official - Last Name:RUSSO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:808-294-3332
Mailing Address - Street 1:8513 NE HAZEL DELL AVE
Mailing Address - Street 2:SUITE #102
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98665-8068
Mailing Address - Country:US
Mailing Address - Phone:360-450-3926
Mailing Address - Fax:360-450-3926
Practice Address - Street 1:250 WARD AVE
Practice Address - Street 2:SUITE #170
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96814-4015
Practice Address - Country:US
Practice Address - Phone:808-294-3332
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-19
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD14968174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty