Provider Demographics
NPI:1255542486
Name:RUSSONELLA, MICHAEL C (DO)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:C
Last Name:RUSSONELLA
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Gender:M
Credentials:DO
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Mailing Address - Street 1:6 BRIGHTON ROAD STE 101
Mailing Address - Street 2:NORTH JERSEY ORTHOPAEDIC & SPORTS MEDICINE INSTITUTE LL
Mailing Address - City:CLIFTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07012-1647
Mailing Address - Country:US
Mailing Address - Phone:973-340-1940
Mailing Address - Fax:973-340-1958
Practice Address - Street 1:6 BRIGHTON ROAD STE 101
Practice Address - Street 2:NORTH JERSEY ORTHOPAEDIC & SPORTS MEDICINE INSTITUTE LL
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07012-1647
Practice Address - Country:US
Practice Address - Phone:973-340-1940
Practice Address - Fax:973-340-1958
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-28
Last Update Date:2016-02-02
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Provider Licenses
StateLicense IDTaxonomies
NY239683-1207XP3100X
NJ25MB08615500207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XP3100XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryPediatric Orthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
180539YATMedicare PIN