Provider Demographics
NPI:1447206933
Name:RUSSELL, RAYMOND S (MD)
Entity Type:Individual
Prefix:DR
First Name:RAYMOND
Middle Name:S
Last Name:RUSSELL
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 1:4000 MIAMISBURG CENTERVILLE RD STE 207
Mailing Address - Street 2:
Mailing Address - City:MIAMISBURG
Mailing Address - State:OH
Mailing Address - Zip Code:45342-3674
Mailing Address - Country:US
Mailing Address - Phone:937-560-2011
Mailing Address - Fax:937-560-2012
Practice Address - Street 1:4000 MIAMISBURG CENTERVILLE RD
Practice Address - Street 2:SUITE 405
Practice Address - City:MIAMISBURG
Practice Address - State:OH
Practice Address - Zip Code:45342-7615
Practice Address - Country:US
Practice Address - Phone:937-560-2011
Practice Address - Fax:937-560-2012
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2020-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35073039208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2169380Medicaid
4051255Medicare ID - Type Unspecified
OHH474590Medicare PIN
H37485Medicare UPIN
OHRU4051254Medicare PIN