Provider Demographics
NPI:1053403428
Name:RUSSO, WILLIAM L
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:L
Last Name:RUSSO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8060 WOLF RIVER BLVD
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38138-1727
Mailing Address - Country:US
Mailing Address - Phone:901-271-1000
Mailing Address - Fax:901-271-2161
Practice Address - Street 1:8060 WOLF RIVER BLVD
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38138-1727
Practice Address - Country:US
Practice Address - Phone:901-271-1000
Practice Address - Fax:901-271-2161
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000007142207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNB03577Medicare UPIN
TN3173153Medicare ID - Type Unspecified