1821103029 NPI number — DR. RUSSELL E CARLSON M.D.

Table of content: DR. RUSSELL E CARLSON M.D. (NPI 1821103029)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821103029 NPI number — DR. RUSSELL E CARLSON M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CARLSON
Provider First Name:
RUSSELL
Provider Middle Name:
E
Provider Name Prefix Text:
DR.
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:
1821103029
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/28/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 7
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BUFFALO
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14207-0007
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
716-462-4415
Provider Business Mailing Address Fax Number:
716-303-7008

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1093 DELAWARE AVE APT 5
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BUFFALO
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14209-1655
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
716-462-4415
Provider Business Practice Location Address Fax Number:
716-303-7008
Provider Enumeration Date:
08/20/2006

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: 208G00000X , with the licence number:  189175 , 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: 7099868 . This is a "GHI" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 000526654001 . This is a "BLUE CROSS/ BLUE SHIELD" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 010549324 . This is a "NOVA INSURANCE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 040426002783 . This is a "FIDELIS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 010549324 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 00025759601 . This is a "UNIVERA HEALTHCARE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 2197606 . This is a "INDEPENDENT HEALTH" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 780002093 . This is a "RAILROAD MCR" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 02212417 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: PAR05802 . This is a "NORTH AMERICAN ADMINISTRT" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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