Provider Demographics
NPI:1417343278
Name:AVELLANA, RUSSELL LLOYD
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:LLOYD
Last Name:AVELLANA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 E HURON ST
Mailing Address - Street 2:SUITE 1-200
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-2909
Mailing Address - Country:US
Mailing Address - Phone:312-503-1851
Mailing Address - Fax:
Practice Address - Street 1:240 E HURON ST
Practice Address - Street 2:SUITE 1-200
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2909
Practice Address - Country:US
Practice Address - Phone:312-503-1851
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-08
Last Update Date:2016-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA60672295363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant