Provider Demographics
NPI:1164470092
Name:WHITE, RUSSELL ANDREW (MD)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:ANDREW
Last Name:WHITE
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 1:120 N COMMERCE AVE
Mailing Address - Street 2:SUITE 230
Mailing Address - City:FRONT ROYAL
Mailing Address - State:VA
Mailing Address - Zip Code:22630-4417
Mailing Address - Country:US
Mailing Address - Phone:540-635-0760
Mailing Address - Fax:540-635-0771
Practice Address - Street 1:120 N COMMERCE AVE
Practice Address - Street 2:SUITE 230
Practice Address - City:FRONT ROYAL
Practice Address - State:VA
Practice Address - Zip Code:22630-4417
Practice Address - Country:US
Practice Address - Phone:540-635-0760
Practice Address - Fax:540-635-0771
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2011-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101244275207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1164470092Medicaid
VAP00676756OtherMEDICARE RR
WV3810013577Medicaid
C33149Medicare UPIN
WV3810013577Medicaid