Provider Demographics
NPI:1174664858
Name:RUSSO, ROCCO (MD)
Entity Type:Individual
Prefix:
First Name:ROCCO
Middle Name:
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 1:2570 ROUTE 9W STE 10
Mailing Address - Street 2:
Mailing Address - City:CORNWALL
Mailing Address - State:NY
Mailing Address - Zip Code:12518-1370
Mailing Address - Country:US
Mailing Address - Phone:845-220-3100
Mailing Address - Fax:845-534-2940
Practice Address - Street 1:127 MAIN ST
Practice Address - Street 2:
Practice Address - City:HIGHLAND FALLS
Practice Address - State:NY
Practice Address - Zip Code:10928-4019
Practice Address - Country:US
Practice Address - Phone:845-446-4076
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2018-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT035913207Q00000X
NY259143207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT010035913CTOtherANTHEM
NY03421327Medicaid
CT1174664858Medicaid
CT2V9661OtherHEALTHNET