Provider Demographics
NPI:1285645200
Name:RUSSO, LOUIS (MD)
Entity Type:Individual
Prefix:
First Name:LOUIS
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 1:246 PLEASANT ST.
Mailing Address - Street 2:MEMORIAL BUILDING, WEST, GROUND FLOOR
Mailing Address - City:CONCORD
Mailing Address - State:NH
Mailing Address - Zip Code:03301-2548
Mailing Address - Country:US
Mailing Address - Phone:603-224-1725
Mailing Address - Fax:603-227-7557
Practice Address - Street 1:246 PLEASANT ST.
Practice Address - Street 2:MEMORIAL BUILDING, WEST, GROUND FLOOR
Practice Address - City:CONCORD
Practice Address - State:NH
Practice Address - Zip Code:03301-2548
Practice Address - Country:US
Practice Address - Phone:603-224-1725
Practice Address - Fax:603-227-7557
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101263233208G00000X
ME014997208G00000X
PAMD050220L208G00000X
NH20944208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102709991Medicaid
PA102709991Medicaid