Provider Demographics
NPI:1235254699
Name:NAPLES NEPHROLOGY P A
Entity Type:Organization
Organization Name:NAPLES NEPHROLOGY P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:STEVEN
Authorized Official - Last Name:RUSSO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:239-513-1002
Mailing Address - Street 1:878 109TH AVE N
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34108-1821
Mailing Address - Country:US
Mailing Address - Phone:239-513-1002
Mailing Address - Fax:239-513-1915
Practice Address - Street 1:878 109TH AVE N
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34108-1821
Practice Address - Country:US
Practice Address - Phone:239-513-1002
Practice Address - Fax:239-513-1915
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-21
Last Update Date:2008-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME83306174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL263246200Medicaid
FL39198OtherBLUE CROSS BLUE SHIELD
FL263246200Medicaid