Provider Demographics
NPI:1568460921
Name:RUSS, PETER CRIAG (MD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:CRIAG
Last Name:RUSS
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 1:1269 US HWY 221A
Mailing Address - Street 2:
Mailing Address - City:FOREST CITY
Mailing Address - State:NC
Mailing Address - Zip Code:28043-5921
Mailing Address - Country:US
Mailing Address - Phone:828-657-5371
Mailing Address - Fax:828-657-9190
Practice Address - Street 1:1269 US HWY 221A
Practice Address - Street 2:
Practice Address - City:FOREST CITY
Practice Address - State:NC
Practice Address - Zip Code:28043-5921
Practice Address - Country:US
Practice Address - Phone:828-657-5371
Practice Address - Fax:828-657-9190
Is Sole Proprietor?:No
Enumeration Date:2005-07-11
Last Update Date:2023-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT028399207Q00000X
NC2007-00384207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5910498Medicaid
CT001283994Medicaid
P00716054OtherMEDICARE RAILROAD
NC5910498Medicaid
CTE01516Medicare UPIN
NC2023009Medicare PIN