Provider Demographics
NPI:1558452532
Name:RUSSO, KATHLEEN F (MD)
Entity Type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:F
Last Name:RUSSO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:129 WOODSON ST
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:NC
Mailing Address - Zip Code:28144-3255
Mailing Address - Country:US
Mailing Address - Phone:704-636-5576
Mailing Address - Fax:704-636-1755
Practice Address - Street 1:129 WOODSON ST
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:NC
Practice Address - Zip Code:28144-3255
Practice Address - Country:US
Practice Address - Phone:704-636-5576
Practice Address - Fax:704-636-1755
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2013-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC97003842080A0000X, 207NP0225X, 2080C0008X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
No207NP0225XAllopathic & Osteopathic PhysiciansDermatologyPediatric Dermatology
No2080C0008XAllopathic & Osteopathic PhysiciansPediatricsChild Abuse Pediatrics
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1032HOtherBCBS
NC891032HMedicaid
NC560988747OtherCIGNA HEALTHCARE
NC284339OtherMAMSI
NC8382976OtherAETNA
NC20522OtherPARTNERS
NC72589OtherMEDCOST PREFERRED
NC1241179OtherUNITED HEALTHCARE
NC413263OtherPHCS
NC284339OtherMAMSI