Provider Demographics
NPI:1376342824
Name:RUSSU, MARIANNA VLADIMIROVNA (RT(R))
Entity type:Individual
Prefix:
First Name:MARIANNA
Middle Name:VLADIMIROVNA
Last Name:RUSSU
Suffix:
Gender:F
Credentials:RT(R)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3800 MICHAELS CREEK WAY
Mailing Address - Street 2:
Mailing Address - City:LOGANVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30052-5183
Mailing Address - Country:US
Mailing Address - Phone:510-695-4721
Mailing Address - Fax:
Practice Address - Street 1:3800 MICHAELS CREEK WAY
Practice Address - Street 2:
Practice Address - City:LOGANVILLE
Practice Address - State:GA
Practice Address - Zip Code:30052-5183
Practice Address - Country:US
Practice Address - Phone:510-695-4721
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-10
Last Update Date:2025-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
I089047247100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes247100000XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistGroup - Single Specialty