Provider Demographics
NPI:1891791786
Name:RUSSO, JOSEPH SCOTT (DO)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:SCOTT
Last Name:RUSSO
Suffix:
Gender:M
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:PO BOX 125
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:IA
Mailing Address - Zip Code:50162-0125
Mailing Address - Country:US
Mailing Address - Phone:574-903-7101
Mailing Address - Fax:
Practice Address - Street 1:1300 JOHNSON ST
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-3406
Practice Address - Country:US
Practice Address - Phone:574-903-7101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-24
Last Update Date:2019-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IADO-03591208M00000X
IN02001759A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP00186778OtherRAILROAD MEDICARE
IN000000355430OtherBLUE CROSS/BLUE SHIELD
IN200120950Medicaid
INP00186778OtherRAILROAD MEDICARE
IN000000355430OtherBLUE CROSS/BLUE SHIELD