Provider Demographics
NPI:1073699252
Name:SHATFORD, RUSSELL ALEXANDER (MD)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:ALEXANDER
Last Name:SHATFORD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:315 E BROADWAY
Practice Address - Street 2:SUITE 195
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-3700
Practice Address - Country:US
Practice Address - Phone:502-629-4263
Practice Address - Fax:502-629-4282
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2021-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY307822086S0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0105XAllopathic & Osteopathic PhysiciansSurgerySurgery of the Hand
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000057058UOtherHUMANA - LAH
KY4632527OtherCIGNA - LAH
KY64307820Medicaid
KY000000694192OtherANTHEM - LAH
KY121306OtherSIHO - LAH
KY50030992OtherPASSPORT/PASSPORT ADVANTAGE - LAH
F85459Medicare UPIN
KY50030992OtherPASSPORT/PASSPORT ADVANTAGE - LAH