Individual
JOHN L RUSSO
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
1025 MARSH ST, MANKATO, MN 56001-4752
(507) 625-4031
(507) 385-6497
Mailing address
1025 MARSH ST, MANKATO, MN 56001-4752
(507) 625-4031
Taxonomy
Speciality
Code
Description
License number
State
207P00000X
Emergency Medicine Physician
Primary
105790
MN
207P00000X
Emergency Medicine Physician
48135-020
WI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
34676800
—
WI
01
—
389906599
TRICARE NORTH REGION
—
01
—
389906599001
BCBS OF WI
WI
01
—
P00247500
MEDICARE RAILROAD
WI
Enumeration date
06/30/2006
Last updated
09/27/2011
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