Provider Demographics
NPI:1407837396
Name:PORTENOY, RUSSELL KEITH (MD)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:KEITH
Last Name:PORTENOY
Suffix:
Gender:M
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:MJHS HOSPICE AND PALLIATIVE CARE
Mailing Address - Street 2:39 BROADWAY #R FL
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10006
Mailing Address - Country:US
Mailing Address - Phone:212-649-5560
Mailing Address - Fax:212-649-5544
Practice Address - Street 1:MJHS HOSPICE AND PALLIATIVE CARE
Practice Address - Street 2:39 BROADWAY #R FL
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10006
Practice Address - Country:US
Practice Address - Phone:212-649-5560
Practice Address - Fax:212-649-5544
Is Sole Proprietor?:No
Enumeration Date:2005-11-08
Last Update Date:2021-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1464752084N0400X, 2084H0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084H0002XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyHospice and Palliative Medicine
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00906634Medicaid
NY04D653Medicare ID - Type Unspecified
NY00906634Medicaid