Provider Demographics
NPI:1235122870
Name:RUSSELL, JAMES PATRICK (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:PATRICK
Last Name:RUSSELL
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 1:13800 W NORTH AVE
Mailing Address - Street 2:STE 100
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53005-4974
Mailing Address - Country:US
Mailing Address - Phone:262-754-4488
Mailing Address - Fax:262-754-4940
Practice Address - Street 1:13800 W NORTH AVE
Practice Address - Street 2:STE 100
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-4974
Practice Address - Country:US
Practice Address - Phone:262-754-4488
Practice Address - Fax:262-754-4940
Is Sole Proprietor?:No
Enumeration Date:2005-08-30
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI47855020207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34688800Medicaid
WIP00368881OtherRAILROAD MEDICARE
WIP00384061OtherRAILROAD MEDICARE
WIP00364352OtherRAILROAD MEDICARE
$$$$$$$$$002OtherBLUE CROSS/BLUE SHIELD
WI34688800Medicaid