Provider Demographics
NPI:1700089422
Name:DELRUSSO, TIMOTHY CARL (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:CARL
Last Name:DELRUSSO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1541 UNION ST
Mailing Address - Street 2:
Mailing Address - City:SCHENECTADY
Mailing Address - State:NY
Mailing Address - Zip Code:12309-6001
Mailing Address - Country:US
Mailing Address - Phone:518-382-2077
Mailing Address - Fax:
Practice Address - Street 1:1541 UNION ST
Practice Address - Street 2:FIRST FLOOR
Practice Address - City:SCHENECTADY
Practice Address - State:NY
Practice Address - Zip Code:12309-6001
Practice Address - Country:US
Practice Address - Phone:518-382-2077
Practice Address - Fax:518-382-2077
Is Sole Proprietor?:No
Enumeration Date:2007-06-08
Last Update Date:2021-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY165387-1174400000X
NY165387208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY51E871OtherBLUE CROSS BLUE SHIELD
NY52178BMedicare ID - Type Unspecified
NY51E871OtherBLUE CROSS BLUE SHIELD