Provider Demographics
NPI:1609319680
Name:WIEN, RUSSELL
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:
Last Name:WIEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:128 BOULEVARD APT 14
Mailing Address - Street 2:
Mailing Address - City:PASSAIC
Mailing Address - State:NJ
Mailing Address - Zip Code:07055-4769
Mailing Address - Country:US
Mailing Address - Phone:973-916-9996
Mailing Address - Fax:
Practice Address - Street 1:128 BOULEVARD APT 14
Practice Address - Street 2:
Practice Address - City:PASSAIC
Practice Address - State:NJ
Practice Address - Zip Code:07055-4769
Practice Address - Country:US
Practice Address - Phone:973-916-9996
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-23
Last Update Date:2016-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist