Provider Demographics
NPI:1417095571
Name:OLIVER, RUSSELL WADE (DPM)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:WADE
Last Name:OLIVER
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 766
Mailing Address - Street 2:
Mailing Address - City:SHELBYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37162-0766
Mailing Address - Country:US
Mailing Address - Phone:931-684-8884
Mailing Address - Fax:931-684-8808
Practice Address - Street 1:635 N. MAIN STREET
Practice Address - Street 2:SUITE A
Practice Address - City:SHELBYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37160-3235
Practice Address - Country:US
Practice Address - Phone:931-684-8884
Practice Address - Fax:931-684-8808
Is Sole Proprietor?:No
Enumeration Date:2007-02-01
Last Update Date:2009-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDPM0000000524213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3157415OtherBLUE CROSS BLUE SHIELD
TN480025490OtherMEDICARE RAILROAD
TNTN0101OtherAMERICHOICE
TN1454420Medicaid
TN4096890001Medicare NSC
TNTN0101OtherAMERICHOICE
TN3352792Medicare PIN