Provider Demographics
NPI:1164488458
Name:RUSSO, PAUL H (MD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:H
Last Name:RUSSO
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 1:305 E 12TH ST
Mailing Address - Street 2:
Mailing Address - City:KAUKAUNA
Mailing Address - State:WI
Mailing Address - Zip Code:54130-2865
Mailing Address - Country:US
Mailing Address - Phone:920-766-4656
Mailing Address - Fax:920-766-4659
Practice Address - Street 1:305 E 12TH ST
Practice Address - Street 2:
Practice Address - City:KAUKAUNA
Practice Address - State:WI
Practice Address - Zip Code:54130-2865
Practice Address - Country:US
Practice Address - Phone:920-766-4656
Practice Address - Fax:920-766-4659
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2014-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI0029508207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31591400Medicaid
WIE47067Medicare UPIN
WI45044 0005Medicare ID - Type Unspecified