Provider Demographics
NPI:1861490195
Name:RUSSO, PATRICK J JR (MD)
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:J
Last Name:RUSSO
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:2555 COURT DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-2134
Mailing Address - Country:US
Mailing Address - Phone:704-868-3256
Mailing Address - Fax:704-868-5870
Practice Address - Street 1:2555 COURT DR
Practice Address - Street 2:SUITE 300
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-2134
Practice Address - Country:US
Practice Address - Phone:704-868-3256
Practice Address - Fax:704-868-5870
Is Sole Proprietor?:No
Enumeration Date:2005-07-11
Last Update Date:2017-06-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
SC26794207RC0000X, 207UN0901X
NC200301049207UN0901X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207UN0901XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC891345RMedicaid
SCN01046Medicaid
SCN01046Medicaid
NC2021232Medicare PIN