Provider Demographics
NPI:1376501049
Name:MEDDERS, RUSSELL GLEN (MD)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:GLEN
Last Name:MEDDERS
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:4600 LAKE BOONE TRAIL
Mailing Address - Street 2:SUITE 100
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27607-7529
Mailing Address - Country:US
Mailing Address - Phone:919-787-1374
Mailing Address - Fax:919-571-8135
Practice Address - Street 1:4600 LAKE BOONE TRAIL
Practice Address - Street 2:SUITE 100
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607-7529
Practice Address - Country:US
Practice Address - Phone:919-787-1374
Practice Address - Fax:919-571-8135
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2021-07-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC29710207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC040002669OtherRAILROAD MEDICARE
NC1050117OtherUNITED HEALTHCARE
NC8958402Medicaid
NC58402OtherBLUE CROSS
NC58402OtherBLUE CROSS
NC213554Medicare PIN