Provider Demographics
NPI:1407897978
Name:LEGREID, RUSSEL JEROME II (MD)
Entity Type:Individual
Prefix:DR
First Name:RUSSEL
Middle Name:JEROME
Last Name:LEGREID
Suffix:II
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 1:6920 POINTE INVERNESS WAY STE 200
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-7934
Mailing Address - Country:US
Mailing Address - Phone:260-479-3513
Mailing Address - Fax:260-479-3520
Practice Address - Street 1:1026 S MAIN ST
Practice Address - Street 2:
Practice Address - City:BLUFFTON
Practice Address - State:IN
Practice Address - Zip Code:46714-3614
Practice Address - Country:US
Practice Address - Phone:260-353-2023
Practice Address - Fax:260-824-7244
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN39319174400000X
IN01074428A174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1407897978Medicaid
IN201250850Medicaid
WI71460Medicare PIN
IN234760007Medicare PIN
WI1407897978Medicaid
WI076500335Medicare PIN