Provider Demographics
NPI:1992790364
Name:RUSSO, CATHY M (MD)
Entity type:Individual
Prefix:
First Name:CATHY
Middle Name:M
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 1:3998 FAIR RIDGE DRIVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22033-2921
Mailing Address - Country:US
Mailing Address - Phone:703-295-9360
Mailing Address - Fax:703-766-9725
Practice Address - Street 1:703 MAIN ST
Practice Address - Street 2:ST. JOSEPH'S REGIONAL MEDICAL CENTER
Practice Address - City:PATERSON
Practice Address - State:NJ
Practice Address - Zip Code:07503-2621
Practice Address - Country:US
Practice Address - Phone:973-754-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-13
Last Update Date:2015-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07377400174400000X, 207L00000X, 208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No174400000XOther Service ProvidersSpecialist
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ058259Medicaid
NJ0069884Medicaid
NJP01230783OtherRAILROAD MEDICARE
NJ058259YU0MMedicare PIN
G58616Medicare UPIN
NJ058259Medicaid