Provider Demographics
NPI:1891828398
Name:RUSSO, SAM (ND, LAC, RMSK)
Entity Type:Individual
Prefix:DR
First Name:SAM
Middle Name:
Last Name:RUSSO
Suffix:
Gender:M
Credentials:ND, LAC, RMSK
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:321 MAIN ST STE B
Mailing Address - Street 2:
Mailing Address - City:WINOOSKI
Mailing Address - State:VT
Mailing Address - Zip Code:05404-1380
Mailing Address - Country:US
Mailing Address - Phone:802-636-4133
Mailing Address - Fax:833-464-3117
Practice Address - Street 1:321 MAIN ST STE B
Practice Address - Street 2:
Practice Address - City:WINOOSKI
Practice Address - State:VT
Practice Address - Zip Code:05404-1380
Practice Address - Country:US
Practice Address - Phone:802-636-4133
Practice Address - Fax:833-464-3117
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2023-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT091-0000176171100000X
VT099-00001312083S0010X, 208D00000X, 175F00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath
No171100000XOther Service ProvidersAcupuncturist
No2083S0010XAllopathic & Osteopathic PhysiciansPreventive MedicineSports Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1015129Medicaid