Provider Demographics
NPI:1093789372
Name:RUSSI, SCOTT ANDREW (MD)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:ANDREW
Last Name:RUSSI
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 1:85182 BLUE HERON WAY
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97405-8671
Mailing Address - Country:US
Mailing Address - Phone:719-243-6631
Mailing Address - Fax:541-868-9306
Practice Address - Street 1:505 NE 87TH AVE STE 301
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98664-1965
Practice Address - Country:US
Practice Address - Phone:360-514-7374
Practice Address - Fax:360-514-7384
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2022-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD61007212207R00000X, 208600000X
ORMD163726208600000X
AK4748208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500659745OtherMEDICAID
ORR170711Medicare PIN