Provider Demographics
NPI:1114953437
Name:KOHL, RUSSELL WADE (MD)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:WADE
Last Name:KOHL
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 1:18005 CANTERBURY RD
Mailing Address - Street 2:
Mailing Address - City:STILWELL
Mailing Address - State:KS
Mailing Address - Zip Code:66085-9334
Mailing Address - Country:US
Mailing Address - Phone:405-706-3821
Mailing Address - Fax:
Practice Address - Street 1:18005 CANTERBURY RD
Practice Address - Street 2:
Practice Address - City:STILWELL
Practice Address - State:KS
Practice Address - Zip Code:66085-9334
Practice Address - Country:US
Practice Address - Phone:405-706-3821
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-26
Last Update Date:2024-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-40467207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKI28023Medicare UPIN