Active NPI
Stephen P Russo, DMD
- Periodontics
- Chicago, IL
National Provider Identifier
1699809202
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Periodontics
- License
- 019-026457
- Practice address
- 25 E. Washington St
Suite 1125
Chicago, IL 60602 - Phone
- (312) 641-2572
- Fax
- (312) 641-6621
- NPI assigned
- Mar 15, 2007
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Periodontics | 1223P0300X | 019-026457 | IL | Primary |
Addresses
Primary practice location
25 E. Washington St
Suite 1125
Chicago, IL 60602
Mailing address
25 E. Washington St
Suite 1125
Chicago, IL 60602
Phone (312) 641-2572
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in IL
- Eligible to order & refer
- Part B services: Yes
- Medical equipment: Yes
- Home health: Yes
- Power mobility devices: No
- Hospice: Yes
Enrollment records 1
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20150505001258 | IL | Order and Referring Only - Oral Surgery | 5294054771 |
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 019-026457 | IL | MD | Periodontist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1173916800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1396224000000",
"number": "1699809202",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "25 E. WASHINGTON ST",
"address_2": "SUITE 1125",
"city": "CHICAGO",
"state": "IL",
"postal_code": "60602",
"telephone_number": "312-641-2572",
"fax_number": "312-641-6621"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "25 E. WASHINGTON ST",
"address_2": "SUITE 1125",
"city": "CHICAGO",
"state": "IL",
"postal_code": "60602",
"telephone_number": "312-641-2572",
"fax_number": "312-641-6621"
}
],
"practiceLocations": [],
"basic": {
"last_name": "RUSSO",
"first_name": "STEPHEN",
"middle_name": "P",
"name_prefix": "Dr.",
"credential": "DMD",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2007-03-15",
"last_updated": "2014-03-31",
"status": "A"
},
"taxonomies": [
{
"code": "1223P0300X",
"taxonomy_group": "",
"desc": "Dentist, Periodontics",
"state": "IL",
"license": "019-026457",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Chicago, IL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 31, 2014; 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.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.