Provider Demographics
NPI:1497847990
Name:RUSSONIELLO, ALEXANDER PETER (MD)
Entity Type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:PETER
Last Name:RUSSONIELLO
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 1:5 PROGRESS STREET
Mailing Address - Street 2:
Mailing Address - City:EDISON
Mailing Address - State:NJ
Mailing Address - Zip Code:08820
Mailing Address - Country:US
Mailing Address - Phone:908-668-4410
Mailing Address - Fax:908-668-0024
Practice Address - Street 1:5 PROGRESS STREET
Practice Address - Street 2:
Practice Address - City:EDISON
Practice Address - State:NJ
Practice Address - Zip Code:08820
Practice Address - Country:US
Practice Address - Phone:908-668-4410
Practice Address - Fax:908-668-0024
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2016-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA45396207X00000X, 207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1334506Medicaid
NJ1334506Medicaid
069180Medicare ID - Type Unspecified