Provider Demographics
NPI:1215019674
Name:COLARUSSO, MARY ANN (DC)
Entity Type:Individual
Prefix:DR
First Name:MARY ANN
Middle Name:
Last Name:COLARUSSO
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3075 SOUTHWESTERN BLVD
Mailing Address - Street 2:SUITE 208
Mailing Address - City:ORCHARD PARK
Mailing Address - State:NY
Mailing Address - Zip Code:14127-1749
Mailing Address - Country:US
Mailing Address - Phone:716-662-0900
Mailing Address - Fax:716-740-8059
Practice Address - Street 1:3671 SOUTHWESTERN BLVD
Practice Address - Street 2:SUITE 213
Practice Address - City:ORCHARD PARK
Practice Address - State:NY
Practice Address - Zip Code:14127-1752
Practice Address - Country:US
Practice Address - Phone:716-662-0900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2015-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX007452-1111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY231531Medicare ID - Type Unspecified