NPIMap

Individual provider Active NPI

Paul H Russo, MD

  • Family Medicine Physician
  • Kaukauna, WI
National Provider Identifier
1164488458
Registry record updated Nov 26, 2014
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
License
0029508 Issued in WI
Practice address
305 E 12TH St
Kaukauna, WI 54130-2865
Phone
(920) 766-4656
Fax
(920) 766-4659
NPI assigned
Apr 25, 2006
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Nov 26, 2014

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X 0029508 WI Primary

Addresses

Primary practice location

305 E 12TH St
Kaukauna, WI 54130-2865

Mailing address

305 E 12TH St
Kaukauna, WI 54130-2865
Phone (920) 766-4656

Other identifiers 1

IdentifierTypeStateIssuer
31591400MedicaidWI

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in WI
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20100524000036 WI Practitioner - Family Practice 8123028420 Reassigns benefits to 4 organizations

Care Compare profile

Medicare Care Compare
Specialty
Family Practice
Education
Southern Illinois University School of Medicine, 1987
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices
Kaukauna Clinic, S.C.Group PAC ID 5597765891, 8 clinicians

Practice addresses (Care Compare)

305 E 12TH St
Kaukauna, WI 54130-2865
Phone (920) 766-4656

Hospital & facility affiliations

Procedures performed for Medicare patients

ProcedureNumber of procedures
Melanoma (skin cancer) excision1-10
Removal of skin lesions1-10
Skin biopsy1-10

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Medicine

State licenses

LicenseStateTypeSpecialty
0029508WIMDFamily Medicine Physician

Practice roles

OrganizationSpecialtyStatusNew patients
University of Wisconsin Medical Foundation, Inc CurrentSince Oct 1, 2014 Accepting new patients
Thedacare, Incorporated Family Medicine CurrentSince Mar 1, 2020 Accepting new patients
Kaukauna Clinic, S.C. Family Medicine CurrentSince Sep 1, 1990 Accepting new patients
University of Wisconsin Medical Foundation, Inc CurrentSince Oct 1, 2014 Accepting new patients
Mosaic Family Health, Inc Family Medicine CurrentSince Jul 1, 2015 Accepting new patients
Frederick Health Hospital Inc Past Accepting new patients

Locations

229 S Morrison St
Appleton, WI 54911
Phone (920) 832-2783

100 N Oneida St
Appleton, WI 54911
Phone (920) 832-2783

4480 W Spencer St
Appleton, WI 54914
Phone (920) 738-4800

835 S Van Buren St
Green Bay, WI 54301
Phone (888) 901-7246

305 E 12th St
Kaukauna, WI 54130
Phone (920) 731-3111

600 Highland Ave
Madison, WI 53792
Phone (608) 263-0325

600 N Westhaven Dr
Oshkosh, WI 54904
Phone (920) 237-5000

Interoperability endpoints

  • Direct secure messaging: prusso21054@direct.thedacare.org

Organizations & group practices 6

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

Hospital & facility affiliations 13

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

View all 13

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1145923200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1416960000000",
    "number": "1164488458",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "305 E 12TH ST",
            "city": "KAUKAUNA",
            "state": "WI",
            "postal_code": "541302865",
            "telephone_number": "920-766-4656",
            "fax_number": "920-766-4659"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "305 E 12TH ST",
            "city": "KAUKAUNA",
            "state": "WI",
            "postal_code": "541302865",
            "telephone_number": "920-766-4656",
            "fax_number": "920-766-4659"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "RUSSO",
        "first_name": "PAUL",
        "middle_name": "H",
        "name_prefix": "Dr.",
        "credential": "MD",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-04-25",
        "last_updated": "2014-11-26",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "WI",
            "license": "0029508",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "31591400",
            "state": "WI"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Kaukauna, WI

Sources for this page

Verify at the official NPI Registry.