Provider Demographics
NPI:1275577405
Name:STEPHANIE F RUSSO MD PEDIATRICS P.C.
Entity Type:Organization
Organization Name:STEPHANIE F RUSSO MD PEDIATRICS P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:G
Authorized Official - Last Name:WICKHAM
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:814-838-3480
Mailing Address - Street 1:3910 CAUGHEY RD
Mailing Address - Street 2:SUITE 170
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16506-4041
Mailing Address - Country:US
Mailing Address - Phone:814-838-3480
Mailing Address - Fax:814-838-3489
Practice Address - Street 1:3910 CAUGHEY RD
Practice Address - Street 2:SUITE 170
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16506-4096
Practice Address - Country:US
Practice Address - Phone:814-838-3480
Practice Address - Fax:814-838-3489
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD043940L208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA690247Medicare ID - Type Unspecified
PAF06562Medicare UPIN