Provider Demographics
NPI:1306076039
Name:SERRANO RUSSI, ALVARO H (MD)
Entity type:Individual
Prefix:
First Name:ALVARO
Middle Name:H
Last Name:SERRANO RUSSI
Suffix:
Gender:M
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:PO BOX 699
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:TN
Mailing Address - Zip Code:37684-0699
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:325 N. STATE OF FRANKLIN ROAD
Practice Address - Street 2:GROUND FL
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604
Practice Address - Country:US
Practice Address - Phone:423-439-7320
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-15
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN65362207SG0201X, 208000000X
PAMD436046208D00000X
CAC1422548207SG0201X
IA39570208000000X
PAMT194028207SG0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207SG0201XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical Genetics (M.D.)
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ074608Medicaid