Provider Demographics
NPI:1104860964
Name:MEDBERY, RUSSELL S JR
Entity Type:Individual
Prefix:MR
First Name:RUSSELL
Middle Name:S
Last Name:MEDBERY
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:360 TOLLAND TPKE
Mailing Address - Street 2:SUITE 3B
Mailing Address - City:MANCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06042-1771
Mailing Address - Country:US
Mailing Address - Phone:860-646-1157
Mailing Address - Fax:860-646-9877
Practice Address - Street 1:360 TOLLAND TPKE
Practice Address - Street 2:SUITE 3B
Practice Address - City:MANCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06042-1771
Practice Address - Country:US
Practice Address - Phone:860-646-1157
Practice Address - Fax:860-646-9877
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000040367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
R96201Medicare UPIN