Provider Demographics
NPI:1326097874
Name:RUSSOMANO, SALVATORE J (MD)
Entity Type:Individual
Prefix:
First Name:SALVATORE
Middle Name:J
Last Name:RUSSOMANO
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:PO BOX 8627
Mailing Address - Street 2:
Mailing Address - City:CHERRY HILL
Mailing Address - State:NJ
Mailing Address - Zip Code:08002-0627
Mailing Address - Country:US
Mailing Address - Phone:856-755-1616
Mailing Address - Fax:856-755-0098
Practice Address - Street 1:3100 HINGSTON AVE STE 104
Practice Address - Street 2:
Practice Address - City:EGG HARBOR TOWNSHIP
Practice Address - State:NJ
Practice Address - Zip Code:08234-4409
Practice Address - Country:US
Practice Address - Phone:888-985-2727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2022-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA0509100208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ5503400Medicaid
NJ223233709OtherTAX ID
NJ1119428OtherHORIZON NJ HEALTH
NJ1258829OtherUNITED HEALTHCARE
NJ250004594OtherRAILROAD MEDICARE
NJ0313495000OtherAMERIHEALTH HMO
NJ487258OtherAMERIHEALTH PPO
11535OtherAIG MVA/WORKMANS COMP
4306370OtherAETNA HMO/PPO
NJATS024OtherOXFORD
NJ487258OtherAMERIHEALTH PPO
NJ5503400Medicaid