Provider Demographics
NPI:1508979436
Name:CRAIG, RUSSELL WAYNE (DO)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:WAYNE
Last Name:CRAIG
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 1:17901 HALL RD
Mailing Address - Street 2:
Mailing Address - City:MACOMB TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48044
Mailing Address - Country:US
Mailing Address - Phone:586-412-0900
Mailing Address - Fax:586-412-9767
Practice Address - Street 1:17901 HALL RD
Practice Address - Street 2:
Practice Address - City:MACOMB TWP
Practice Address - State:MI
Practice Address - Zip Code:48044
Practice Address - Country:US
Practice Address - Phone:586-412-0900
Practice Address - Fax:586-412-9767
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2010-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101011400207YX0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5500330OtherBCBS OF MI
MI3385222Medicaid
F54927Medicare UPIN
MI3385222Medicaid