Provider Demographics
NPI:1164465571
Name:RUSSO, MICHAEL SCOTT (DC)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:SCOTT
Last Name:RUSSO
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 N CENTRE AVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:ROCKVILLE CENTRE
Mailing Address - State:NY
Mailing Address - Zip Code:11570-3937
Mailing Address - Country:US
Mailing Address - Phone:516-763-2600
Mailing Address - Fax:516-763-4218
Practice Address - Street 1:100 N CENTRE AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:ROCKVILLE CENTRE
Practice Address - State:NY
Practice Address - Zip Code:11570-3937
Practice Address - Country:US
Practice Address - Phone:516-763-2600
Practice Address - Fax:516-763-4218
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2010-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX006933111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY322612OtherACN GROUP ID#
NY0002357OtherSELECT PRO ID#
NY5303872OtherGHI / ALIGNIS ID#
NYP744425OtherOXFORD ID #
NY1C9303OtherHEALTHNET ID#
NYNY06933OtherLANDMARK HC ID#
NY1295243OtherUNITED HEALTHCARE ID#
NY63503OtherVYTRA ID#
NY5597187OtherAETNA ID #
NYP62591639OtherMULTIPLAN ID#
NYCO6933-8OtherNYS WORK COMP #
NY1295243OtherUNITED HEALTHCARE ID#
NYX4967-1Medicare ID - Type UnspecifiedEMPIRE MEDICARE NUMBER