Provider Demographics
NPI:1609968452
Name:RAPHAELY, RUSSELL C (MD)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:C
Last Name:RAPHAELY
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:NEMOURS CHILDRENS CLINIC
Mailing Address - Street 2:P.O. BOX 404112
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-0001
Mailing Address - Country:US
Mailing Address - Phone:904-390-3610
Mailing Address - Fax:904-288-5890
Practice Address - Street 1:A.I. DUPONT HOSPITAL FOR CHILDREN
Practice Address - Street 2:1600 ROCKLAND ROAD
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19803-3607
Practice Address - Country:US
Practice Address - Phone:302-651-4000
Practice Address - Fax:302-651-4945
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2008-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC10005241207L00000X, 207LP3000X, 2080P0203X
NJMA06427200207L00000X, 207LP3000X, 2080P0203X
PAMD007844E207L00000X, 207LP3000X, 2080P0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP3000XAllopathic & Osteopathic PhysiciansAnesthesiologyPediatric Anesthesiology
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD4399102Medicaid
KY64572621Medicaid
LA1569895Medicaid
NY956134Medicaid
TXP8B187880Medicaid
ID806298000Medicaid
PA000684273Medicaid
NJ0224006Medicaid
TXP8B187880Medicaid