Provider Demographics
NPI:1588745392
Name:RUSSO, MARK WILLIAM (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:WILLIAM
Last Name:RUSSO
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 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1126 N CHURCH ST
Practice Address - Street 2:STE 201
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27401-1000
Practice Address - Country:US
Practice Address - Phone:336-235-0866
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2024-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9500209207R00000X, 207RG0100X, 207RT0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RT0003XAllopathic & Osteopathic PhysiciansInternal MedicineTransplant Hepatology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCQ0020AMedicaid
NC8973999Medicaid
NC2212807CMedicare PIN
NC2212807DMedicare PIN
NCG06120Medicare UPIN
NC8973999Medicaid