Provider Demographics
NPI:1932524154
Name:DIRUSSO, AVERI
Entity Type:Individual
Prefix:
First Name:AVERI
Middle Name:
Last Name:DIRUSSO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:DAI
Other - Middle Name:OK
Other - Last Name:MOON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD, PA
Mailing Address - Street 1:C-83 OMEGA DRIVE
Mailing Address - Street 2:ST FRANCIS HOSPITAL
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19713
Mailing Address - Country:US
Mailing Address - Phone:302-731-0600
Mailing Address - Fax:
Practice Address - Street 1:C-83 OMEGA DRIVE
Practice Address - Street 2:ST FRANCIS HOSPITAL
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19713-2064
Practice Address - Country:US
Practice Address - Phone:302-731-0600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-25
Last Update Date:2014-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC1-0002324282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE070989Medicare PIN