Provider Demographics
NPI:1821030214
Name:RUSSO, ROMOLO HARRIS (MD)
Entity Type:Individual
Prefix:DR
First Name:ROMOLO
Middle Name:HARRIS
Last Name:RUSSO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:601 JOHN ST
Mailing Address - Street 2:SUITE M-170
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49007-5341
Mailing Address - Country:US
Mailing Address - Phone:269-343-3939
Mailing Address - Fax:269-343-3948
Practice Address - Street 1:601 JOHN ST
Practice Address - Street 2:SUITE M-170
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49007-5341
Practice Address - Country:US
Practice Address - Phone:269-343-3939
Practice Address - Fax:269-343-3948
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2010-06-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301036631207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1403912121OtherBCBS PIN
155407OtherGREAT LAKES HLTH PLN
MI4832089-10Medicaid
4325832OtherAETNA PIN
155407OtherGREAT LAKES HLTH PLN
D91306Medicare UPIN
MIC15823Medicare PIN
MI4832089-10Medicaid
MI1403912121OtherBCBS PIN