Provider Demographics
NPI:1073741153
Name:GERMEROTH, JOHN RUSSUM (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:RUSSUM
Last Name:GERMEROTH
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 1:600 GREEN VALLEY RD
Mailing Address - Street 2:SUITE 304
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27408-7722
Mailing Address - Country:US
Mailing Address - Phone:336-282-4840
Mailing Address - Fax:
Practice Address - Street 1:501 N ELAM AVE
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27403-1118
Practice Address - Country:US
Practice Address - Phone:336-282-4840
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-26
Last Update Date:2013-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLTRN-14880207L00000X
NC2013-00962207L00000X
SCLL31888208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCTL31888OtherSOUTH CAROLINA BOARD OF MEDICAL EXAMINERS
FLTRN-14880OtherFLORIDA BOARD OF MEDICINE
NC2013-00962OtherNORTH CAROLINA MEDICAL BOARD
NCNCD491AMedicare PIN