Provider Demographics
NPI:1811968498
Name:RUSSO, STEPHANIE F (MD)
Entity type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:F
Last Name:RUSSO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3910 CAUGHEY RD
Mailing Address - Street 2:SUITE 170
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16506-4096
Mailing Address - Country:US
Mailing Address - Phone:814-838-3480
Mailing Address - Fax:
Practice Address - Street 1:3910 CAUGHEY RD
Practice Address - Street 2:SUITE 170
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16506-4096
Practice Address - Country:US
Practice Address - Phone:814-838-3480
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-31
Last Update Date:2011-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD043940L208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAF06562Medicare UPIN
PA690247Medicare ID - Type Unspecified