Provider Demographics
NPI:1497799654
Name:RUSSELL, JEFFREY S (DO)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:S
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:327 W CHICAGO ST
Mailing Address - Street 2:
Mailing Address - City:COLDWATER
Mailing Address - State:MI
Mailing Address - Zip Code:49036-2805
Mailing Address - Country:US
Mailing Address - Phone:517-278-8000
Mailing Address - Fax:517-278-8007
Practice Address - Street 1:327 W CHICAGO ST
Practice Address - Street 2:
Practice Address - City:COLDWATER
Practice Address - State:MI
Practice Address - Zip Code:49036-2805
Practice Address - Country:US
Practice Address - Phone:517-278-8000
Practice Address - Fax:517-278-8007
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2013-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101011799207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1C CJ8339OtherMEDICARE RR
MI4836462Medicaid
MI1C CJ8339OtherMEDICARE RR
MIG13533Medicare UPIN
MI4836462Medicaid
MI0M99170003Medicare ID - Type Unspecified