Provider Demographics
NPI:1629239355
Name:RUSS, STEPHANIE JANE (DO)
Entity Type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:JANE
Last Name:RUSS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:STEPHANIE
Other - Middle Name:JANE
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:6626 E. 75TH STREET
Mailing Address - Street 2:SUITE 500
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2890
Mailing Address - Country:US
Mailing Address - Phone:765-298-4569
Mailing Address - Fax:765-298-4568
Practice Address - Street 1:1251 S HUNTZINGER BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:PENDLETON
Practice Address - State:IN
Practice Address - Zip Code:46064
Practice Address - Country:US
Practice Address - Phone:765-298-4567
Practice Address - Fax:765-298-4568
Is Sole Proprietor?:No
Enumeration Date:2008-06-25
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN11014474A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200975760Medicaid
INP01430098OtherRAILROAD MEDICARE
INP01430098OtherRAILROAD MEDICARE
IN200975760Medicaid