Provider Demographics
NPI:1548227606
Name:COULTER, RUSSELL (MD)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:
Last Name:COULTER
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:FAMILY HEALTH CENTRE
Mailing Address - Street 2:207 SOUTH BURNS AVE
Mailing Address - City:SPARTA
Mailing Address - State:IL
Mailing Address - Zip Code:62286
Mailing Address - Country:US
Mailing Address - Phone:618-443-3084
Mailing Address - Fax:
Practice Address - Street 1:FAMILY HEALTH CENTRE
Practice Address - Street 2:207 SOUTH BURNS AVE
Practice Address - City:SPARTA
Practice Address - State:IL
Practice Address - Zip Code:62286
Practice Address - Country:US
Practice Address - Phone:618-443-3084
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2020-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036064147207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILC45822Medicare UPIN