Provider Demographics
NPI:1407852049
Name:RUSSIN, SIMON R (DO)
Entity Type:Individual
Prefix:DR
First Name:SIMON
Middle Name:R
Last Name:RUSSIN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:301 E CITY AVE
Mailing Address - Street 2:SUITE G2
Mailing Address - City:BALA CYNWYD
Mailing Address - State:PA
Mailing Address - Zip Code:19004-1708
Mailing Address - Country:US
Mailing Address - Phone:610-617-4177
Mailing Address - Fax:610-617-4170
Practice Address - Street 1:301 E CITY AVE
Practice Address - Street 2:SUITE G2
Practice Address - City:BALA CYNWYD
Practice Address - State:PA
Practice Address - Zip Code:19004-1708
Practice Address - Country:US
Practice Address - Phone:610-617-4177
Practice Address - Fax:610-617-4170
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-27
Last Update Date:2011-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS009908L207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001697374Medicaid
PA10935353OtherCAQH
PAG80707Medicare UPIN
PA001697374Medicaid