Individual
MARTIN T RUSSO JR.
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DO
Contact information
Practice address
1310 WISCONSIN AVE STE 103, GRAND HAVEN, MI 49417
(616) 846-2640
(616) 846-3110
Mailing address
1310 WISCONSIN AVE, STE 101, GRAND HAVEN, MI 49417-2472
(616) 847-5604
(616) 846-0141
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
5101014183
MI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
4094275
—
MI
Enumeration date
08/08/2006
Last updated
06/11/2018
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