1629239355 NPI number — DR. STEPHANIE JANE RUSS DO

Table of content: DR. STEPHANIE JANE RUSS DO (NPI 1629239355)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629239355 NPI number — DR. STEPHANIE JANE RUSS DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RUSS
Provider First Name:
STEPHANIE
Provider Middle Name:
JANE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WILSON
Provider Other First Name:
STEPHANIE
Provider Other Middle Name:
JANE
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
DO
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1629239355
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/27/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6626 E. 75TH STREET
Provider Second Line Business Mailing Address:
SUITE 500
Provider Business Mailing Address City Name:
INDIANAPOLIS
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46250-2890
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
765-298-4569
Provider Business Mailing Address Fax Number:
765-298-4568

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1251 S HUNTZINGER BLVD
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
PENDLETON
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46064
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
765-298-4567
Provider Business Practice Location Address Fax Number:
765-298-4568
Provider Enumeration Date:
06/25/2008

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: 207Q00000X , with the licence number:  11014474A , 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: 200975760 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: P01430098 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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