Provider Demographics
NPI:1477806214
Name:MICHAEL B. RUSSO MD INC
Entity Type:Organization
Organization Name:MICHAEL B. RUSSO MD INC
Other - Org Name:HAWAII PACIFIC DEEG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:B
Authorized Official - Last Name:RUSSO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:808-294-3332
Mailing Address - Street 1:8513 NE HAZEL DELL AVE
Mailing Address - Street 2:SUITE #102
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98665-8068
Mailing Address - Country:US
Mailing Address - Phone:360-450-3926
Mailing Address - Fax:360-450-3926
Practice Address - Street 1:320 WARD AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96814-4001
Practice Address - Country:US
Practice Address - Phone:808-294-3332
Practice Address - Fax:808-748-2920
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MICHAEL B. RUSSO MD INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-10-17
Last Update Date:2015-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site