Provider Demographics
NPI:1598928517
Name:VALLEY FAMILY CARE- M. JOSEPH RUSSO MD PA
Entity Type:Organization
Organization Name:VALLEY FAMILY CARE- M. JOSEPH RUSSO MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MELCHIORRE
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:RUSSO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-279-5116
Mailing Address - Street 1:128 VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:CLIFTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07013-1121
Mailing Address - Country:US
Mailing Address - Phone:973-279-5116
Mailing Address - Fax:973-279-8899
Practice Address - Street 1:128 VALLEY RD
Practice Address - Street 2:
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07013-1121
Practice Address - Country:US
Practice Address - Phone:973-279-5116
Practice Address - Fax:973-279-8899
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-09
Last Update Date:2021-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA04879600207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJE77370Medicare UPIN