Provider Demographics
NPI:1063437515
Name:RUSSO, SUZANNE M (MD)
Entity type:Individual
Prefix:
First Name:SUZANNE
Middle Name:M
Last Name:RUSSO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20800 HARVARD RD
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:HIGHLAND HILLS
Mailing Address - State:OH
Mailing Address - Zip Code:44122-7202
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11100 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44106-1716
Practice Address - Country:US
Practice Address - Phone:216-844-3951
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN402802085R0001X
AL243942085R0001X
NC97-003852085R0001X
MS190982085R0001X
OH35.1257232085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0135692Medicaid
NC126MHOtherBCBS
AL920006473OtherRAILROAD MEDICARE
NC89126MHMedicaid
AL051513420OtherBLUE CROSS
NC89126MHMedicaid
NC126MHOtherBCBS
NC2280549CMedicare Oscar/Certification
MS920000067Medicare ID - Type UnspecifiedALSO MEDICAID
OHH353230Medicare PIN
TN3335118Medicare ID - Type UnspecifiedALSO MEDICAID
OH0135692Medicaid