Provider Demographics
NPI:1457012114
Name:MICHAEL C RUSSONELLA ORTHOPEDIC SURGEON PC
Entity Type:Organization
Organization Name:MICHAEL C RUSSONELLA ORTHOPEDIC SURGEON PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:RUSSONELLA
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:973-340-1940
Mailing Address - Street 1:14 N MAIN ST STE 1
Mailing Address - Street 2:
Mailing Address - City:SPRING VALLEY
Mailing Address - State:NY
Mailing Address - Zip Code:10977-4942
Mailing Address - Country:US
Mailing Address - Phone:973-340-1940
Mailing Address - Fax:
Practice Address - Street 1:14 N MAIN ST STE 1
Practice Address - Street 2:
Practice Address - City:SPRING VALLEY
Practice Address - State:NY
Practice Address - Zip Code:10977-4942
Practice Address - Country:US
Practice Address - Phone:973-340-1940
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-05
Last Update Date:2022-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Single Specialty