Provider Demographics
NPI:1689684771
Name:DEGROOTE, RUSSELL A (MD)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:A
Last Name:DEGROOTE
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 1:265 LISEL LN
Mailing Address - Street 2:
Mailing Address - City:PORT ANGELES
Mailing Address - State:WA
Mailing Address - Zip Code:98362-7492
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7559 N TONGASS AVE
Practice Address - Street 2:
Practice Address - City:KETCHIKAN
Practice Address - State:AK
Practice Address - Zip Code:99901-9182
Practice Address - Country:US
Practice Address - Phone:907-247-9999
Practice Address - Fax:206-339-1460
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK114055207X00000X
NE26594207X00000X
WAMD60661553207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO30471753Medicaid
CO805149Medicare PIN
COG85740Medicare UPIN
CO30471753Medicaid