Provider Demographics
NPI:1790780427
Name:RUSSO-COLT, MARY BERTHA (DO)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:BERTHA
Last Name:RUSSO-COLT
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 1:1202 STATE ST
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16501-1914
Mailing Address - Country:US
Mailing Address - Phone:814-454-4530
Mailing Address - Fax:814-456-2375
Practice Address - Street 1:1202 STATE ST
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16501-1914
Practice Address - Country:US
Practice Address - Phone:814-454-4530
Practice Address - Fax:814-456-2375
Is Sole Proprietor?:No
Enumeration Date:2005-06-17
Last Update Date:2015-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS006175L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001168615OtherPA MEDICAID
PA001168615OtherPA MEDICAID
202090D7AMedicare PIN