Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 204C00000X | Sports Medicine Doctor | 224966 | NY |
NPI | 1417984295 |
---|---|
Provider Name | Dr. Andrew Russo |
First Address | Brooklyn, NY 11209-3205 |
Second Address | Brooklyn, NY 11209-3205 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 27/06/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
H83156 | (02) | NY |