Provider Demographics
NPI:1073717658
Name:RUSSO, MARC WILLIAM (MD)
Entity Type:Individual
Prefix:DR
First Name:MARC
Middle Name:WILLIAM
Last Name:RUSSO
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:100 ROUTE 59
Mailing Address - Street 2:SUITE 105
Mailing Address - City:SUFFERN
Mailing Address - State:NY
Mailing Address - Zip Code:10901-4927
Mailing Address - Country:US
Mailing Address - Phone:845-357-5775
Mailing Address - Fax:845-357-5777
Practice Address - Street 1:300 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:EAST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07018-2819
Practice Address - Country:US
Practice Address - Phone:973-266-8400
Practice Address - Fax:845-357-5777
Is Sole Proprietor?:No
Enumeration Date:2007-06-14
Last Update Date:2013-10-02
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Provider Licenses
StateLicense IDTaxonomies
NY255454207L00000X
NJ25MA08706700207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03534714Medicaid
3885700619OtherMYUTMB 3885700619-COMMERCIAL NUMBER
NJ0243451Medicaid
NJ0243451Medicaid