Provider Demographics
NPI:1194838938
Name:THOMPSON, RUSSELL C (MD)
Entity Type:Individual
Prefix:MR
First Name:RUSSELL
Middle Name:C
Last Name:THOMPSON
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 1:1623 HASLETT RD
Mailing Address - Street 2:
Mailing Address - City:HASLETT
Mailing Address - State:MI
Mailing Address - Zip Code:48840
Mailing Address - Country:US
Mailing Address - Phone:517-339-2100
Mailing Address - Fax:517-339-4620
Practice Address - Street 1:1623 HASLETT RD
Practice Address - Street 2:
Practice Address - City:HASLETT
Practice Address - State:MI
Practice Address - Zip Code:48840
Practice Address - Country:US
Practice Address - Phone:517-614-1104
Practice Address - Fax:517-694-1692
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2010-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301407218207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
7388025OtherAETNA
700C312390OtherBCN
6600006OtherPHP
7388025OtherAETNA
E56163Medicare UPIN