Provider Demographics
NPI:1588957500
Name:MICHAEL B. RUSSO, MD, INC
Entity type:Organization
Organization Name:MICHAEL B. RUSSO, MD, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER, DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:BRIAN
Authorized Official - Last Name:RUSSO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-775-8731
Mailing Address - Street 1:320 WARD AVE STE 107
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96814-4016
Mailing Address - Country:US
Mailing Address - Phone:808-294-3332
Mailing Address - Fax:808-748-2920
Practice Address - Street 1:320 WARD AVE STE 107
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96814-4016
Practice Address - Country:US
Practice Address - Phone:808-294-3332
Practice Address - Fax:808-748-2920
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-24
Last Update Date:2024-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI14968174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty