Provider Demographics
NPI:1518932441
Name:MAGGIO, RUSSELL PHILIP (MD)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:PHILIP
Last Name:MAGGIO
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 1:125 LATTIMORE RD
Mailing Address - Street 2:SUITE 256
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14620-4159
Mailing Address - Country:US
Mailing Address - Phone:585-271-5250
Mailing Address - Fax:
Practice Address - Street 1:125 LATTIMORE RD
Practice Address - Street 2:SUITE 256
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14620-4159
Practice Address - Country:US
Practice Address - Phone:585-271-5250
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-22
Last Update Date:2007-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY161925207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY010161925OtherBLUE CHOICE
NYMD198COtherPREFERRED CARE
NY1392OtherBLUE SHIELD
NY11575AMedicare PIN
NY1392OtherBLUE SHIELD
NY010161925OtherBLUE CHOICE