Provider Demographics
NPI:1437169737
Name:RUSS, BRIAN W (MD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:W
Last Name:RUSS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5300 FAR HILLS AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45429-2347
Mailing Address - Country:US
Mailing Address - Phone:937-312-3830
Mailing Address - Fax:937-433-9612
Practice Address - Street 1:5300 FAR HILLS AVE
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45429-2347
Practice Address - Country:US
Practice Address - Phone:937-312-3830
Practice Address - Fax:937-433-9612
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2016-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH58606207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH759842OtherAETNA
OH3380966OtherUNITED HEALTHCARE
P00977283OtherRAILROAD MEDICARE
OH000000731123OtherANTHEM BC/BS
OH7766410OtherCIGNA
OH759842OtherAETNA