Provider Demographics
NPI:1689710881
Name:RUSSO, ANTHONY F (MD)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:F
Last Name:RUSSO
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 1:591 STONEHENGE DRIVE
Mailing Address - Street 2:
Mailing Address - City:LITITZ
Mailing Address - State:PA
Mailing Address - Zip Code:17543
Mailing Address - Country:US
Mailing Address - Phone:717-560-9451
Mailing Address - Fax:
Practice Address - Street 1:591 STONEHENGE DRIVE
Practice Address - Street 2:
Practice Address - City:LITITZ
Practice Address - State:PA
Practice Address - Zip Code:17543
Practice Address - Country:US
Practice Address - Phone:717-560-9451
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD041636E2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1151823Medicaid
PA1151823Medicaid
C08338Medicare UPIN