Provider Demographics
NPI:1659345346
Name:RUSSUM, JEFFREY HAROLD (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:HAROLD
Last Name:RUSSUM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JEFFREY
Other - Middle Name:H
Other - Last Name:RUSSUM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:8170 33RD AVE S
Mailing Address - Street 2:MS 21110Q
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55425-4516
Mailing Address - Country:US
Mailing Address - Phone:651-254-3456
Mailing Address - Fax:651-254-9673
Practice Address - Street 1:640 JACKSON ST
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55101-2502
Practice Address - Country:US
Practice Address - Phone:651-254-3456
Practice Address - Fax:651-254-9673
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2015-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN34942207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN826590900Medicaid
MN826590900Medicaid