Provider Demographics
NPI:1124185483
Name:DIRUSSO, STEPHEN M (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:M
Last Name:DIRUSSO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4422 THIRD AVE
Mailing Address - Street 2:DEPT OF SURGERY 2ND FLOOR MILLS BUILDING
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10457
Mailing Address - Country:US
Mailing Address - Phone:718-960-6127
Mailing Address - Fax:
Practice Address - Street 1:4422 3RD AVE
Practice Address - Street 2:ST. BARNABAS HOSPITAL DEPT SURGERY 2ND FLOR MILLS BLVD
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10457-2545
Practice Address - Country:US
Practice Address - Phone:718-960-6127
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2008-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2037722086S0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1724423Medicaid
NY61L901Medicare PIN
NY1724423Medicaid