Russell John Ridulfo, PA

Primary specialty

Physician AssistantTaxonomy code 363A00000X

Practice address

12 Maple Glen LN
Nesconset, NY 11767-1712

Phone

(631) 942-0295

NPI assigned

Jun 3, 2024

Sex

Male

Sole proprietor

Yes

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

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in NY

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: No

Green means eligible to order or refer.

Enrollment records 1

Specialty

Physician Assistant

Education

Other, 2024

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Group practices

Southwest Suffolk Medical PCGroup PAC ID 0244396349, 204 clinicians

Practice addresses (Care Compare)

Hospital & facility affiliations

• St Charles Hospital Hospital, Port Jefferson, NY, CCN 330246

Medicare enrollment (NPD)

Enrolled

Credentials

Physician Assistant

State licenses

Networks

• Healthfirst Medicare Network H1722
• Healthfirst Medicare Network H5989
• Healthfirst Medicare Network H9678
• Healthfirst Medicare Network H3359

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.

• Southwest Suffolk Medical, P.C.

  • Surgical Oncology Physician
  • Smithtown, NY
  • NPI 1104096049
  Medicare reassignment Care Compare group

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

• St Charles Hospital Corp

  dba St. Charles Hospital

  • General Acute Care Hospital
  • Port Jefferson, NY
  • NPI 1164481529
  Care Compare affiliation

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

{
    "created_epoch": "1717372800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1717372800000",
    "number": "1407697683",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "12 MAPLE GLEN LN",
            "city": "NESCONSET",
            "state": "NY",
            "postal_code": "117671712",
            "telephone_number": "631-942-0295"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "12 MAPLE GLEN LN",
            "city": "NESCONSET",
            "state": "NY",
            "postal_code": "117671712",
            "telephone_number": "631-942-0295"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "RIDULFO",
        "first_name": "RUSSELL",
        "middle_name": "JOHN",
        "name_prefix": "Mr.",
        "credential": "PA",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2024-06-03",
        "last_updated": "2024-06-03",
        "certification_date": "2024-06-03",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "NY",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Hillary Reinke, MSED, BCBA, LBA
• James Remien, LMT
• Jeanine Renous
• Samantha Marie Repalone
• Maria T Ribaudo
• Julia James Rivera
• Syeda Zunabia Batool Rizvi
• Ann Rizza
• Mary Rodriguez, M.S.CCC-SLP
• Joanna Rongo

• Physician Assistant in Nesconset, NY
• Providers in Nesconset, NY by specialty
• Physician Assistant in New York

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 3, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.