Provider Demographics
NPI:1598738874
Name:RUSS, EDMOND V III (MD)
Entity Type:Individual
Prefix:
First Name:EDMOND
Middle Name:V
Last Name:RUSS
Suffix:III
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 1:1725 HARRODSBURG RD STE 100
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40504-3601
Mailing Address - Country:US
Mailing Address - Phone:859-278-7226
Mailing Address - Fax:859-276-1540
Practice Address - Street 1:1725 HARRODSBURG RD STE 100
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40504-3601
Practice Address - Country:US
Practice Address - Phone:859-278-7226
Practice Address - Fax:859-276-1540
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-08
Last Update Date:2021-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY534392085R0202X
OH35082471R2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2387297Medicaid
KYK300750OtherMEDICARE
KY7100669920Medicaid