Provider Demographics
NPI:1720070824
Name:RUSSO CLINIC-A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:RUSSO CLINIC-A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:H
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:985-384-1562
Mailing Address - Street 1:PO BOX 2347
Mailing Address - Street 2:
Mailing Address - City:MORGAN CITY
Mailing Address - State:LA
Mailing Address - Zip Code:70381-2347
Mailing Address - Country:US
Mailing Address - Phone:985-384-1562
Mailing Address - Fax:985-385-6749
Practice Address - Street 1:1124 7TH ST
Practice Address - Street 2:
Practice Address - City:MORGAN CITY
Practice Address - State:LA
Practice Address - Zip Code:70380-1951
Practice Address - Country:US
Practice Address - Phone:985-384-1562
Practice Address - Fax:985-385-6749
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA12846B207R00000X
LA016985207R00000X
LA02397R208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Not Answered208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1167053Medicaid
LA57959Medicare ID - Type Unspecified