1144205113 NPI number — DR. PATRICK W RUSSELL D.O.

Table of content: DR. PATRICK W RUSSELL D.O. (NPI 1144205113)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144205113 NPI number — DR. PATRICK W RUSSELL D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RUSSELL
Provider First Name:
PATRICK
Provider Middle Name:
W
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.O.
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:
1144205113
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/19/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1219 GREENLEAF BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ELKHART
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46514-1365
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
574-536-4753
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
615 N MICHIGAN ST
Provider Second Line Business Practice Location Address:
1ST FL HOSPITALIST STE
Provider Business Practice Location Address City Name:
SOUTH BEND
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46601-1033
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
574-647-3050
Provider Business Practice Location Address Fax Number:
574-647-1094
Provider Enumeration Date:
12/13/2005

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: 2084N0400X , with the licence number:  02001219 , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000000215919 . This is a "BLUE SHIELD" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 100114080 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 130024231 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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