Provider Demographics
NPI:1891785051
Name:ROTONDO, RUSSELL (MD)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:
Last Name:ROTONDO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7557B DANNAHER DR STE 225
Mailing Address - Street 2:
Mailing Address - City:POWELL
Mailing Address - State:TN
Mailing Address - Zip Code:37849-3568
Mailing Address - Country:US
Mailing Address - Phone:865-647-5800
Mailing Address - Fax:865-647-5979
Practice Address - Street 1:7557B DANNAHER DR STE 225
Practice Address - Street 2:
Practice Address - City:POWELL
Practice Address - State:TN
Practice Address - Zip Code:37849-3568
Practice Address - Country:US
Practice Address - Phone:865-647-5800
Practice Address - Fax:865-647-5979
Is Sole Proprietor?:No
Enumeration Date:2005-10-27
Last Update Date:2019-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN21440207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ018627Medicaid
TN1520090Medicaid
P00852734Medicare PIN
60068971Medicare PIN
TN3859123Medicare PIN
TNF54564Medicare UPIN
TN103I066535Medicare PIN