Provider Demographics
NPI:1609836907
Name:BUFALINO, RUSSELL S (MD,JD)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:S
Last Name:BUFALINO
Suffix:
Gender:M
Credentials:MD,JD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:313 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:OLD FORGE
Mailing Address - State:PA
Mailing Address - Zip Code:18518-1606
Mailing Address - Country:US
Mailing Address - Phone:570-451-1122
Mailing Address - Fax:570-451-0541
Practice Address - Street 1:313 S MAIN ST
Practice Address - Street 2:
Practice Address - City:OLD FORGE
Practice Address - State:PA
Practice Address - Zip Code:18518-1606
Practice Address - Country:US
Practice Address - Phone:570-451-1122
Practice Address - Fax:570-451-0541
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-23
Last Update Date:2010-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD008940E222Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA7289228OtherAETNA
PA1563559Medicaid
PABU108435OtherBLUE CROSS BLUE SHIELD
PA817264Other1ST PRIORITY
PABU108435OtherBLUE CROSS BLUE SHIELD
D65123Medicare UPIN