Provider Demographics
NPI:1457304214
Name:HERMUS, RUSSELL J (MD)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:J
Last Name:HERMUS
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 1:1211 FISH HATCHERY RD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53715-1909
Mailing Address - Country:US
Mailing Address - Phone:608-252-8000
Mailing Address - Fax:608-283-7160
Practice Address - Street 1:1211 FISH HATCHERY RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53715-1909
Practice Address - Country:US
Practice Address - Phone:608-252-8000
Practice Address - Fax:608-283-7160
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2022-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI31322-020207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1457304214Medicaid
WI31670700Medicaid
E67108Medicare UPIN
WI080052298Medicare PIN
WI034374150Medicare PIN