Provider Demographics
NPI:1598925356
Name:RUSSCOL, EPHAT HADAS (MD)
Entity Type:Individual
Prefix:DR
First Name:EPHAT
Middle Name:HADAS
Last Name:RUSSCOL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 COMMERCIAL ST
Mailing Address - Street 2:
Mailing Address - City:MALDEN
Mailing Address - State:MA
Mailing Address - Zip Code:02148-5509
Mailing Address - Country:US
Mailing Address - Phone:781-322-5101
Mailing Address - Fax:781-322-5820
Practice Address - Street 1:105 COMMERCIAL ST
Practice Address - Street 2:
Practice Address - City:MALDEN
Practice Address - State:MA
Practice Address - Zip Code:02148-5509
Practice Address - Country:US
Practice Address - Phone:781-322-5101
Practice Address - Fax:781-322-5820
Is Sole Proprietor?:No
Enumeration Date:2008-06-14
Last Update Date:2012-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA246598208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110089410AMedicaid