Provider Demographics
NPI:1255307435
Name:SAMPLE, JAMES RUSSELL JR (DO)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:RUSSELL
Last Name:SAMPLE
Suffix:JR
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 1:800 FAIRVIEW RD
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15238-1706
Mailing Address - Country:US
Mailing Address - Phone:412-656-4557
Mailing Address - Fax:
Practice Address - Street 1:532 W PITTSBURGH ST
Practice Address - Street 2:
Practice Address - City:GREENSBURG
Practice Address - State:PA
Practice Address - Zip Code:15601-2239
Practice Address - Country:US
Practice Address - Phone:724-832-4358
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-27
Last Update Date:2022-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS013679207P00000X
OH34.008207207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHI11503Medicare UPIN