Provider Demographics
NPI:1275560195
Name:RUSSOMANNO HEALTH CENTER
Entity Type:Organization
Organization Name:RUSSOMANNO HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING
Authorized Official - Prefix:MISS
Authorized Official - First Name:COLLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:DOUGHERTY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-263-1047
Mailing Address - Street 1:350 BLOOMFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07003
Mailing Address - Country:US
Mailing Address - Phone:201-263-1047
Mailing Address - Fax:
Practice Address - Street 1:350 BLOOMFIELD AVE
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07003
Practice Address - Country:US
Practice Address - Phone:201-263-1047
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA02891700207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1258508Medicaid