Provider Demographics
NPI:1093794356
Name:MAIESE, RUSSELL L (MD)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:L
Last Name:MAIESE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:14275 MIDWAY RD
Mailing Address - Street 2:SUITE 400
Mailing Address - City:ADDISON
Mailing Address - State:TX
Mailing Address - Zip Code:75001-3614
Mailing Address - Country:US
Mailing Address - Phone:866-436-9631
Mailing Address - Fax:610-271-4245
Practice Address - Street 1:1 GREENWICH PL
Practice Address - Street 2:
Practice Address - City:SHELTON
Practice Address - State:CT
Practice Address - Zip Code:06484-4618
Practice Address - Country:US
Practice Address - Phone:866-436-9631
Practice Address - Fax:203-929-2344
Is Sole Proprietor?:No
Enumeration Date:2006-01-13
Last Update Date:2015-05-29
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CT036583207ZP0102X, 207ZH0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ZH0000XAllopathic & Osteopathic PhysiciansPathologyHematology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTF91761Medicare UPIN