Provider Demographics
NPI:1942298369
Name:RUSSO, SCOTT S (MD)
Entity type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:S
Last Name:RUSSO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 LEFFINGWELL AVE NE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-6406
Mailing Address - Country:US
Mailing Address - Phone:616-459-7101
Mailing Address - Fax:616-942-6879
Practice Address - Street 1:750 E BELTLINE AVE NE
Practice Address - Street 2:SUITE 301
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-6049
Practice Address - Country:US
Practice Address - Phone:616-459-7101
Practice Address - Fax:616-942-6879
Is Sole Proprietor?:No
Enumeration Date:2005-10-10
Last Update Date:2013-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301405099207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the Spine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4761530Medicaid
0D14869Medicare ID - Type Unspecified
MI4761530Medicaid