Provider Demographics
NPI:1417937723
Name:RUSSELL, SANDRA K (DO)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:K
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:401 S BALLENGER HWY
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48532-3638
Mailing Address - Country:US
Mailing Address - Phone:810-342-1000
Mailing Address - Fax:810-342-1590
Practice Address - Street 1:2104 JOLLY RD
Practice Address - Street 2:SUITE 220
Practice Address - City:OKEMOS
Practice Address - State:MI
Practice Address - Zip Code:48864-6043
Practice Address - Country:US
Practice Address - Phone:517-975-1400
Practice Address - Fax:517-975-1405
Is Sole Proprietor?:No
Enumeration Date:2006-01-20
Last Update Date:2012-11-29
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI5101010708207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0700083OtherPHYSICIANS HEALTH PLAN
MI160C311260OtherBLUE CHOICE
MI160C311260OtherBLUE CARE NETWORK
MI1006244OtherMCLAREN HEALTH PLAN
MIE68082OtherHEALTH NET FEDERAL SERVIC
MI4460493Medicaid
MI160C311260OtherCOMMUNITY BLUE PPO
MI1006244OtherHEALTH ADVANTAGE NETWORK
MI1652300205OtherBLUE CROSS BLUE SHIELD
MI160C311260OtherBLUE CROSS BLUE SHIELD
MIE68082Medicare UPIN
MI4460493Medicaid