Provider Demographics
NPI:1134134422
Name:SHU, RUSSELL S (MD)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:S
Last Name:SHU
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 1:35 PEARL ST STE 100
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301-1195
Mailing Address - Country:US
Mailing Address - Phone:508-588-8034
Mailing Address - Fax:508-588-5969
Practice Address - Street 1:35 PEARL ST STE 100
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-2866
Practice Address - Country:US
Practice Address - Phone:508-588-8034
Practice Address - Fax:508-588-5969
Is Sole Proprietor?:No
Enumeration Date:2006-07-29
Last Update Date:2018-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA204533207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3209396Medicaid
MAA31106Medicare PIN
MA3209396Medicaid
MAH16597Medicare UPIN