Provider Demographics
NPI:1083691133
Name:RUSSELL, STEPHEN R (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:R
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:8201 NORTHWOODS DR
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68505-3092
Mailing Address - Country:US
Mailing Address - Phone:402-465-5600
Mailing Address - Fax:402-327-6074
Practice Address - Street 1:3262 SALT CREEK CIR
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68504-4761
Practice Address - Country:US
Practice Address - Phone:402-465-5600
Practice Address - Fax:402-437-0852
Is Sole Proprietor?:No
Enumeration Date:2005-12-29
Last Update Date:2017-03-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NE20029208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025151600Medicaid
NE47079049100Medicaid
NE10026369300Medicaid
NE47079049112Medicaid