Provider Demographics
NPI:1588717177
Name:RUSSO, STEFANI ANN (MD)
Entity type:Individual
Prefix:DR
First Name:STEFANI
Middle Name:ANN
Last Name:RUSSO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:700 WALNUT ST FL 2
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19106-3505
Mailing Address - Country:US
Mailing Address - Phone:215-503-4779
Mailing Address - Fax:215-503-4922
Practice Address - Street 1:700 WALNUT ST FL 2
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19106-3505
Practice Address - Country:US
Practice Address - Phone:215-503-4779
Practice Address - Fax:215-503-4922
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2018-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT046659207R00000X
NY259999207R00000X
SC36913207R00000X
PAMD456132207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine