Provider Demographics
NPI:1326013699
Name:RUSSELL, BERNADITH (MD)
Entity Type:Individual
Prefix:
First Name:BERNADITH
Middle Name:
Last Name:RUSSELL
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 1:61 IRVING PL APT LLB
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10003-2330
Mailing Address - Country:US
Mailing Address - Phone:212-741-7800
Mailing Address - Fax:212-741-7801
Practice Address - Street 1:61 IRVING PL APT LLB
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003-2330
Practice Address - Country:US
Practice Address - Phone:212-741-7800
Practice Address - Fax:212-741-7801
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-21
Last Update Date:2019-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY223267207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02202784Medicaid
NY02202784Medicaid
NY518E41Medicare PIN