Provider Demographics
NPI:1033278155
Name:RUSSELL DEGROOTE MD PC
Entity Type:Organization
Organization Name:RUSSELL DEGROOTE MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:A
Authorized Official - Last Name:DEGROOTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-888-3381
Mailing Address - Street 1:PO BOX 1099
Mailing Address - Street 2:
Mailing Address - City:WARD COVE
Mailing Address - State:AK
Mailing Address - Zip Code:99928-1099
Mailing Address - Country:US
Mailing Address - Phone:907-247-9999
Mailing Address - Fax:
Practice Address - Street 1:7559 N. TONGASS AVE
Practice Address - Street 2:
Practice Address - City:KETCHIKAN
Practice Address - State:AK
Practice Address - Zip Code:99901-9182
Practice Address - Country:US
Practice Address - Phone:907-247-9999
Practice Address - Fax:206-339-1460
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-06
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE26594207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO51100231Medicaid
CO51100231Medicaid
COC805148Medicare PIN