1043219496 NPI number — TODD E RUSSELL MD

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043219496 NPI number — TODD E RUSSELL MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RUSSELL
Provider First Name:
TODD
Provider Middle Name:
E
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1043219496
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/03/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2109 HUGHES DR
Provider Second Line Business Mailing Address:
SUITE 450
Provider Business Mailing Address City Name:
TOLEDO
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43606-3856
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
419-291-2003
Provider Business Mailing Address Fax Number:
419-479-6977

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2109 HUGHES DR
Provider Second Line Business Practice Location Address:
SUITE 450
Provider Business Practice Location Address City Name:
TOLEDO
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43606-3856
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
419-291-2003
Provider Business Practice Location Address Fax Number:
419-479-6977
Provider Enumeration Date:
07/19/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2086S0129X , with the licence number:  35074626 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000000493404 . This is a "ANTHEM" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 03444 . This is a "PARAMOUNT" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 5773778 . This is a "AETNA" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 21-01841 . This is a "UHC" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 2215678 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4957870 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 10221 . This is a "HEALTH PLAN OF MI" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: P00366278 . This is a "RRMC" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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