Provider Demographics
NPI:1437125580
Name:FIORELLA, RUSSELL M (MD)
Entity Type:Individual
Prefix:MR
First Name:RUSSELL
Middle Name:M
Last Name:FIORELLA
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 1:26460 NETWORK PL
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-1264
Mailing Address - Country:US
Mailing Address - Phone:773-257-2500
Mailing Address - Fax:773-257-2076
Practice Address - Street 1:1501 S CALIFORNIA AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60608-1732
Practice Address - Country:US
Practice Address - Phone:773-542-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2016-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR4H12207ZP0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO202584017Medicaid
MOE86855Medicare UPIN
MO2632847AMedicare ID - Type UnspecifiedMEDICARE NUMBER