Provider Demographics
NPI:1114923893
Name:ORTHOPAEDIC SPECIALTY GROUP, P.C.
Entity Type:Organization
Organization Name:ORTHOPAEDIC SPECIALTY GROUP, P.C.
Other - Org Name:ROBERT D. RUSSO, M.D. & ASSOCIATES RADIOLOGY, P.C.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:JUDITH
Authorized Official - Middle Name:
Authorized Official - Last Name:ORTIZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-538-5233
Mailing Address - Street 1:PO BOX 6128
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06606-0128
Mailing Address - Country:US
Mailing Address - Phone:203-538-5233
Mailing Address - Fax:203-538-5246
Practice Address - Street 1:305 BLACK ROCK TPKE
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CT
Practice Address - Zip Code:06825
Practice Address - Country:US
Practice Address - Phone:203-337-2600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-27
Last Update Date:2018-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0168052085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004107894Medicaid
C02013Medicare PIN