Provider Demographics
NPI:1386664407
Name:RUSSELL, BERTRAM ROYCE JR (MD)
Entity Type:Individual
Prefix:
First Name:BERTRAM
Middle Name:ROYCE
Last Name:RUSSELL
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:B.
Other - Middle Name:ROYCE
Other - Last Name:RUSSELL
Other - Suffix:JR
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:416 YOUNGSFORD LN
Mailing Address - Street 2:
Mailing Address - City:GLADWYNE
Mailing Address - State:PA
Mailing Address - Zip Code:19035-1609
Mailing Address - Country:US
Mailing Address - Phone:610-658-2244
Mailing Address - Fax:610-658-2403
Practice Address - Street 1:701 E MARSHALL ST
Practice Address - Street 2:
Practice Address - City:WEST CHESTER
Practice Address - State:PA
Practice Address - Zip Code:19380-4412
Practice Address - Country:US
Practice Address - Phone:610-431-5132
Practice Address - Fax:610-363-9892
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2008-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD020168E2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA000741496Medicaid
PA163289Medicare ID - Type Unspecified
PAC32488Medicare UPIN