1568438497 NPI number — MR. RUSSELL W DERN PH.D

Table of content: MR. RUSSELL W DERN PH.D (NPI 1568438497)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568438497 NPI number — MR. RUSSELL W DERN PH.D

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DERN
Provider First Name:
RUSSELL
Provider Middle Name:
W
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PH.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:
1568438497
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/22/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
204 COOK RD
Provider Second Line Business Mailing Address:
SUITE 400
Provider Business Mailing Address City Name:
LEBANON
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45036-9600
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
513-228-7800
Provider Business Mailing Address Fax Number:
513-725-2231

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
975 KINGSIVEW DRIVE
Provider Second Line Business Practice Location Address:
BLDG A
Provider Business Practice Location Address City Name:
LEBANON
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45036-9562
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
513-228-7800
Provider Business Practice Location Address Fax Number:
513-228-7846
Provider Enumeration Date:
02/28/2006

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: 103TC0700X , with the licence number:  3444 , 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: 11489916 . This is a "CAQH" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 0630884 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000012343 . This is a "ANTHEM PIN" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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