Provider Demographics
NPI:1487992871
Name:RUSSAK DERMATOLOGY PC
Entity type:Organization
Organization Name:RUSSAK DERMATOLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:E
Authorized Official - Last Name:RUSSAK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:212-684-5964
Mailing Address - Street 1:115 E 57TH ST
Mailing Address - Street 2:12TH FLOOR
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10022-2049
Mailing Address - Country:US
Mailing Address - Phone:212-684-5964
Mailing Address - Fax:
Practice Address - Street 1:115 E 57TH ST
Practice Address - Street 2:12TH FLOOR
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10022-2049
Practice Address - Country:US
Practice Address - Phone:212-684-5964
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-21
Last Update Date:2013-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY249307-1261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty