Provider Demographics
NPI:1083024327
Name:RUSSO, MARK (ATC, CSCS)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:RUSSO
Suffix:
Gender:M
Credentials:ATC, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5823 WIDEWATERS PKWY
Mailing Address - Street 2:
Mailing Address - City:EAST SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13057-3081
Mailing Address - Country:US
Mailing Address - Phone:315-701-4000
Mailing Address - Fax:315-701-4091
Practice Address - Street 1:5823 WIDEWATERS PKWY
Practice Address - Street 2:
Practice Address - City:EAST SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13057-3081
Practice Address - Country:US
Practice Address - Phone:315-701-4000
Practice Address - Fax:315-701-4091
Is Sole Proprietor?:No
Enumeration Date:2014-05-07
Last Update Date:2014-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002388-12255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer