Provider Demographics
NPI:1275692030
Name:RUSSETH, KATHY J (MD)
Entity Type:Individual
Prefix:DR
First Name:KATHY
Middle Name:J
Last Name:RUSSETH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:345 W WASHINGTON AVE STE 307
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53703-6019
Mailing Address - Country:US
Mailing Address - Phone:414-395-5435
Mailing Address - Fax:608-305-8736
Practice Address - Street 1:345 W WASHINGTON AVE STE 307
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53703-6019
Practice Address - Country:US
Practice Address - Phone:414-395-5435
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-07
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI49950-020208D00000X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1275692030OtherMEDICARE/MEDICAID FOR GENERAL PRACTICE SERVICES