Provider Demographics
NPI:1710128699
Name:GARY E RUSSOLILLO MD PC
Entity Type:Organization
Organization Name:GARY E RUSSOLILLO MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:RUSSOLILLO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-521-2200
Mailing Address - Street 1:970 FARMINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06107-2139
Mailing Address - Country:US
Mailing Address - Phone:860-521-2200
Mailing Address - Fax:860-521-2605
Practice Address - Street 1:970 FARMINGTON AVE
Practice Address - Street 2:
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06107-2139
Practice Address - Country:US
Practice Address - Phone:860-521-2200
Practice Address - Fax:860-521-2605
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-23
Last Update Date:2009-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty