Provider Demographics
NPI:1144205113
Name:RUSSELL, PATRICK W (DO)
Entity Type:Individual
Prefix:DR
First Name:PATRICK
Middle Name:W
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1219 GREENLEAF BLVD
Mailing Address - Street 2:
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46514-1365
Mailing Address - Country:US
Mailing Address - Phone:574-536-4753
Mailing Address - Fax:
Practice Address - Street 1:615 N MICHIGAN ST
Practice Address - Street 2:1ST FL HOSPITALIST STE
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46601-1033
Practice Address - Country:US
Practice Address - Phone:574-647-3050
Practice Address - Fax:574-647-1094
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-13
Last Update Date:2023-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN020012192084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000215919OtherBLUE SHIELD
IN100114080Medicaid
IN130024231OtherMEDICARE RAILROAD
IN000000215919OtherBLUE SHIELD
IN186120AMedicare PIN
IN236040150Medicare PIN
IN100114080Medicaid