Provider Demographics
NPI:1659337988
Name:RUSSELL, JEFFREY W (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:W
Last Name:RUSSELL
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 1:85 N GRAND AVE
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:FORT THOMAS
Mailing Address - State:KY
Mailing Address - Zip Code:41075-1793
Mailing Address - Country:US
Mailing Address - Phone:859-781-2628
Mailing Address - Fax:859-572-4403
Practice Address - Street 1:85 N GRAND AVE
Practice Address - Street 2:2ND FLOOR
Practice Address - City:FORT THOMAS
Practice Address - State:KY
Practice Address - Zip Code:41075-1793
Practice Address - Country:US
Practice Address - Phone:859-781-2628
Practice Address - Fax:859-572-4403
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2012-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35037666R208600000X
KY21322208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64213226Medicaid
OH2564238Medicaid
OH2564238Medicaid
KY0957504Medicare PIN
C69332Medicare UPIN
KY64213226Medicaid
P00717161Medicare PIN