Provider Demographics
NPI:1861580672
Name:LARUSSA, PAUL GERARD (MD)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:GERARD
Last Name:LARUSSA
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 1:233 WINTON M BLOUNT LOOP
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36117-3507
Mailing Address - Country:US
Mailing Address - Phone:334-239-2622
Mailing Address - Fax:334-625-7602
Practice Address - Street 1:233 WINTON M BLOUNT LOOP
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36117-3507
Practice Address - Country:US
Practice Address - Phone:334-239-2622
Practice Address - Fax:334-625-7602
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2016-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL000141642084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL510-95129OtherBLUE CROSS PROVIDER #
AL510-95129OtherBLUE CROSS PROVIDER #
AL95129Medicare PIN