Provider Demographics
NPI:1518121623
Name:RUSSELL W. ROBERTSON, M.D.P.C.
Entity Type:Organization
Organization Name:RUSSELL W. ROBERTSON, M.D.P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:WRIGHT
Authorized Official - Last Name:ROBERTSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-246-1203
Mailing Address - Street 1:85 SEYMOUR ST
Mailing Address - Street 2:SUITE 519
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06106-5501
Mailing Address - Country:US
Mailing Address - Phone:860-246-1203
Mailing Address - Fax:860-246-1145
Practice Address - Street 1:85 SEYMOUR ST
Practice Address - Street 2:SUITE 519
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06106-5501
Practice Address - Country:US
Practice Address - Phone:860-246-1203
Practice Address - Fax:860-246-1145
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-17
Last Update Date:2008-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT16087207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT010016087CT01OtherBLUE CROSS
CT1160878Medicaid
CT077233OtherCTC
CTE54479Medicare UPIN
CT040000109Medicare PIN