Provider Demographics
NPI:1689883688
Name:RUSSO, DANA MARIE (DO)
Entity Type:Individual
Prefix:DR
First Name:DANA
Middle Name:MARIE
Last Name:RUSSO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 W MONROE ST
Mailing Address - Street 2:#401
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607-2565
Mailing Address - Country:US
Mailing Address - Phone:312-498-5990
Mailing Address - Fax:
Practice Address - Street 1:1255 MILWAUKEE AVE
Practice Address - Street 2:
Practice Address - City:GLENVIEW
Practice Address - State:IL
Practice Address - Zip Code:60025-2425
Practice Address - Country:US
Practice Address - Phone:847-294-5490
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2008-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036118849207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology