Provider Demographics
NPI:1073717658
Name:RUSSO, MARC WILLIAM (MD)
Entity type:Individual
Prefix:DR
First Name:MARC
Middle Name:WILLIAM
Last Name:RUSSO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:66 W GILBERT ST STE 100
Mailing Address - Street 2:
Mailing Address - City:TINTON FALLS
Mailing Address - State:NJ
Mailing Address - Zip Code:07701-4948
Mailing Address - Country:US
Mailing Address - Phone:732-212-0060
Mailing Address - Fax:732-212-0061
Practice Address - Street 1:7600 RIVER RD
Practice Address - Street 2:
Practice Address - City:NORTH BERGEN
Practice Address - State:NJ
Practice Address - Zip Code:07047-6217
Practice Address - Country:US
Practice Address - Phone:212-854-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-14
Last Update Date:2024-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY255454207L00000X
NJ25MA08706700207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
3885700619OtherMYUTMB 3885700619-COMMERCIAL NUMBER
NY03534714Medicaid
NJ0243451Medicaid
NJ0243451Medicaid