1700551918 NPI number — KIRSTIN JENNA RUSSELL NP

Table of content: KIRSTIN JENNA RUSSELL NP (NPI 1700551918)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700551918 NPI number — KIRSTIN JENNA RUSSELL NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RUSSELL
Provider First Name:
KIRSTIN
Provider Middle Name:
JENNA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
TIDQUIST
Provider Other First Name:
KIRSTIN
Provider Other Middle Name:
J
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1700551918
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/28/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
250 N SHADELAND AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
INDIANAPOLIS
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46219-4959
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8820 S MERIDIAN ST STE 225
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
INDIANAPOLIS
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46217-6064
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-865-6922
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/10/2021

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: 363LP0808X , with the licence number:  71011436A , 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: 300055577 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 264430D16 . This is a "MEDICARE PTAN" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 1102264002 . This is a "ANTHEM PTAN" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: Q00332599 . This is a "RAILROAD PTAN" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 000001614748 . This is a "ANTHEM PTAN" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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