Provider Demographics
NPI:1437184959
Name:MICHAEL RUSS, MD PC
Entity Type:Organization
Organization Name:MICHAEL RUSS, MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:LOYD
Authorized Official - Last Name:RUSS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:516-255-0620
Mailing Address - Street 1:100 DALY BLVD
Mailing Address - Street 2:#2505
Mailing Address - City:OCEANSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11572-6000
Mailing Address - Country:US
Mailing Address - Phone:516-255-0620
Mailing Address - Fax:
Practice Address - Street 1:70 GLEN ST
Practice Address - Street 2:SUITE 380
Practice Address - City:GLEN COVE
Practice Address - State:NY
Practice Address - Zip Code:11542-2855
Practice Address - Country:US
Practice Address - Phone:516-759-2424
Practice Address - Fax:516-759-6627
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY188435261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty