Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN0400X | Neurology | 006107 | MO |
NPI | 1750330767 |
---|---|
Provider Name | Dr. Phyllis S Russo |
First Address | Chesterfield, MO 63017-5735 |
Second Address | Chesterfield, MO 63017-5735 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 08/05/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
49100 | (02) | MO |