Provider Demographics
NPI:1346386992
Name:RUSSEL H. ETTER MD
Entity Type:Organization
Organization Name:RUSSEL H. ETTER MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:S
Authorized Official - Last Name:WOLFGANG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:717-741-3896
Mailing Address - Street 1:55 WYNTRE BROOKE DR
Mailing Address - Street 2:
Mailing Address - City:YORK
Mailing Address - State:PA
Mailing Address - Zip Code:17403-4536
Mailing Address - Country:US
Mailing Address - Phone:717-741-3896
Mailing Address - Fax:717-741-5434
Practice Address - Street 1:55 WYNTRE BROOKE DR
Practice Address - Street 2:
Practice Address - City:YORK
Practice Address - State:PA
Practice Address - Zip Code:17403-4536
Practice Address - Country:US
Practice Address - Phone:717-741-3896
Practice Address - Fax:717-741-5434
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2009-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD008050E261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA03206000OtherCAPITAL BLUE CROSS
PA172355OtherHEALTHAMERICAN PA
PA0004626999OtherAETNA
PA8110175OtherCIGNA
PA000018534OtherHIGHMARK BLUE SHIELD
PA0643575Medicaid
PA03206000OtherCAPITAL BLUE CROSS
PA0643575Medicaid