Provider Demographics
NPI:1417040650
Name:RUSS, JOHN S (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:S
Last Name:RUSS
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 1:1080 BEECHER CROSSING NORTH
Mailing Address - Street 2:
Mailing Address - City:GAHANNA
Mailing Address - State:OH
Mailing Address - Zip Code:43230
Mailing Address - Country:US
Mailing Address - Phone:614-476-4104
Mailing Address - Fax:614-476-5303
Practice Address - Street 1:1080 BEECHER CROSSING NORTH
Practice Address - Street 2:
Practice Address - City:GAHANNA
Practice Address - State:OH
Practice Address - Zip Code:43230
Practice Address - Country:US
Practice Address - Phone:614-476-4104
Practice Address - Fax:614-476-5303
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2011-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35041252207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0394443Medicaid
OH0498254OtherMEDICARE PTAN
OHP00274357Medicare PIN
OH0394443Medicaid