Provider Demographics
NPI:1578564225
Name:OTTLEY, RUSSELL MARK (MD)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:MARK
Last Name:OTTLEY
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:230 SCHILLING CIRCLE #170
Mailing Address - Street 2:ATT: MARY ELLEN CUTHIE
Mailing Address - City:HUNT VALLEY
Mailing Address - State:MD
Mailing Address - Zip Code:21031-1417
Mailing Address - Country:US
Mailing Address - Phone:410-296-4616
Mailing Address - Fax:410-337-5068
Practice Address - Street 1:6701 N CHARLES ST
Practice Address - Street 2:
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21204-6808
Practice Address - Country:US
Practice Address - Phone:410-296-4616
Practice Address - Fax:410-337-5068
Is Sole Proprietor?:No
Enumeration Date:2005-08-03
Last Update Date:2020-05-19
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MDD0035962207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD210071100Medicaid
MDD0035962OtherSTATE LICENSE NUMBER
MD210071100Medicaid
MDE35515Medicare UPIN