Provider Demographics
NPI:1235289281
Name:HIBBARD, RUSSELL LOWELL JR (MD)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:LOWELL
Last Name:HIBBARD
Suffix:JR
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 1:2744 W AB AVE
Mailing Address - Street 2:
Mailing Address - City:PLAINWELL
Mailing Address - State:MI
Mailing Address - Zip Code:49080-9641
Mailing Address - Country:US
Mailing Address - Phone:269-685-2268
Mailing Address - Fax:
Practice Address - Street 1:218 W WALNUT ST
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49007-5131
Practice Address - Country:US
Practice Address - Phone:269-344-7997
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010277732084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOM87090Medicare ID - Type Unspecified
MIB43353Medicare UPIN