Provider Demographics
NPI:1275522039
Name:DAUGHERTY, RUSSELL (MD)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:
Last Name:DAUGHERTY
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 1:1300 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RUSHVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46173-1116
Mailing Address - Country:US
Mailing Address - Phone:765-932-4111
Mailing Address - Fax:765-932-7062
Practice Address - Street 1:1300 N MAIN ST
Practice Address - Street 2:
Practice Address - City:RUSHVILLE
Practice Address - State:IN
Practice Address - Zip Code:46173-1116
Practice Address - Country:US
Practice Address - Phone:765-932-4111
Practice Address - Fax:765-932-7062
Is Sole Proprietor?:No
Enumeration Date:2005-10-14
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01042648A207R00000X, 208000000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200001980Medicaid
IN000000599467OtherANTHEM BCBS
ING28643Medicare UPIN
IN200001980Medicaid