1245269364 NPI number — RUSSELL S ELWELL M.D.

Table of content: RUSSELL S ELWELL M.D. (NPI 1245269364)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245269364 NPI number — RUSSELL S ELWELL M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ELWELL
Provider First Name:
RUSSELL
Provider Middle Name:
S
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1245269364
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/30/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
158 E MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WESTFIELD
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14787-1155
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
716-326-4686
Provider Business Mailing Address Fax Number:
716-326-4628

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
158 E MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WESTFIELD
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14787-1155
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
716-326-4686
Provider Business Practice Location Address Fax Number:
716-326-4628
Provider Enumeration Date:
07/01/2006

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: 207QA0505X , with the licence number:  115079-1 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208D00000X , with the licence number: 115079 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 00607790 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000507267001 . This is a "BLUE CROSS/SHIELD WNY" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 1702196 . This is a "INDEPENDENT HEALTH" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 00010200001 . This is a "UNIVERA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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