Provider Demographics
NPI:1558352211
Name:NOVAK, RUSSELL A (MD)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:A
Last Name:NOVAK
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 1:200 THEDA CLARK MEDICAL PLAZA
Mailing Address - Street 2:SUITE 480
Mailing Address - City:NEENAH
Mailing Address - State:WI
Mailing Address - Zip Code:54956
Mailing Address - Country:US
Mailing Address - Phone:920-729-0608
Mailing Address - Fax:920-729-2902
Practice Address - Street 1:200 THEDA CLARK MEDICAL PLAZA
Practice Address - Street 2:SUITE 480
Practice Address - City:NEENAH
Practice Address - State:WI
Practice Address - Zip Code:54956
Practice Address - Country:US
Practice Address - Phone:920-729-0608
Practice Address - Fax:920-729-2902
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2018-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI48910207R00000X, 207RC0200X, 207RP1001X
NY197207207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34826700Medicaid
WI34826700Medicaid
WI000945445Medicare Oscar/Certification
A53398Medicare UPIN
WI004071460Medicare ID - Type Unspecified
NY01503891Medicaid
NY11285BMedicare ID - Type Unspecified
WI34826700Medicaid