Provider Demographics
NPI:1447380985
Name:RUSSO, RONALD C (MD)
Entity Type:Individual
Prefix:MR
First Name:RONALD
Middle Name:C
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 1:2504 GALEN DRIVE
Mailing Address - Street 2:SUITE 107
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61821-7048
Mailing Address - Country:US
Mailing Address - Phone:217-398-4856
Mailing Address - Fax:217-373-5214
Practice Address - Street 1:2504 GALEN DRIVE
Practice Address - Street 2:SUITE 107
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61821-7048
Practice Address - Country:US
Practice Address - Phone:217-398-4856
Practice Address - Fax:217-373-5214
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
200795Medicare ID - Type Unspecified
C43412Medicare UPIN