Provider Demographics
NPI:1740630938
Name:RUSSILLO, RICHARD WILLIAM (MD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:WILLIAM
Last Name:RUSSILLO
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1550 BOYSON RD
Mailing Address - Street 2:
Mailing Address - City:HIAWATHA
Mailing Address - State:IA
Mailing Address - Zip Code:52233-2362
Mailing Address - Country:US
Mailing Address - Phone:319-743-7300
Mailing Address - Fax:319-743-7311
Practice Address - Street 1:1550 BOYSON RD
Practice Address - Street 2:
Practice Address - City:HIAWATHA
Practice Address - State:IA
Practice Address - Zip Code:52233-2362
Practice Address - Country:US
Practice Address - Phone:319-743-7300
Practice Address - Fax:319-743-7311
Is Sole Proprietor?:No
Enumeration Date:2016-06-17
Last Update Date:2025-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAR-10612207LA0401X, 207LC0200X, 207LH0002X, 207LP2900X, 207LP3000X
IAMD-47149207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LA0401XAllopathic & Osteopathic PhysiciansAnesthesiologyAddiction Medicine
No207LC0200XAllopathic & Osteopathic PhysiciansAnesthesiologyCritical Care Medicine
No207LH0002XAllopathic & Osteopathic PhysiciansAnesthesiologyHospice and Palliative Medicine
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No207LP3000XAllopathic & Osteopathic PhysiciansAnesthesiologyPediatric Anesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAMD-47149OtherMEDICAL LICENSE