Provider Demographics
NPI:1427033927
Name:RUSSO, MARC S (MD)
Entity Type:Individual
Prefix:
First Name:MARC
Middle Name:S
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 1:562 W 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:LITITZ
Mailing Address - State:PA
Mailing Address - Zip Code:17543-1816
Mailing Address - Country:US
Mailing Address - Phone:717-626-2167
Mailing Address - Fax:717-626-1915
Practice Address - Street 1:562 W 2ND AVE
Practice Address - Street 2:
Practice Address - City:LITITZ
Practice Address - State:PA
Practice Address - Zip Code:17543-1816
Practice Address - Country:US
Practice Address - Phone:717-626-2167
Practice Address - Fax:717-626-1915
Is Sole Proprietor?:No
Enumeration Date:2005-12-07
Last Update Date:2007-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD042622L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA578413OtherAETNA HMO
PAP002686OtherGATEWAY HEALTH PLAN
PAG05182OtherHEALTH ASSURANCE
PA02110901OtherCAPITAL BLUE CROSS
PA36691 S1QGOtherGEISINGER HEALTH PLAN
PA5487080OtherAETNA NON-HMO
PA775158OtherHIGHMARK BLUE SHIELD
PA0015140170004Medicaid
PA0015140170001Medicaid
PA02110901OtherCAPITAL BLUE CROSS
PA775158JZEMedicare PIN