Provider Demographics
NPI:1962510636
Name:RUSSO, SAMUEL J (DO)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:J
Last Name:RUSSO
Suffix:
Gender:M
Credentials:DO
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Mailing Address - Street 1:829 N CENTER AVE
Mailing Address - Street 2:SUITE 298
Mailing Address - City:GAYLORD
Mailing Address - State:MI
Mailing Address - Zip Code:49735-1595
Mailing Address - Country:US
Mailing Address - Phone:989-731-7708
Mailing Address - Fax:989-731-7929
Practice Address - Street 1:2572 N US HIGHWAY 131
Practice Address - Street 2:
Practice Address - City:ELMIRA
Practice Address - State:MI
Practice Address - Zip Code:49730-8252
Practice Address - Country:US
Practice Address - Phone:989-731-7700
Practice Address - Fax:989-731-2999
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2013-12-03
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
ORDO15969207Q00000X
MI5101008981207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OF96004OtherGROUP MEDICARE ID
OR500400122Medicaid
ORR150657Medicare PIN