Provider Demographics
NPI:1689867046
Name:RUSSELL W. CRAIG DO, PC
Entity Type:Organization
Organization Name:RUSSELL W. CRAIG DO, PC
Other - Org Name:INSTITUTE FOR EAR NOSE AND THROAT SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:CRAIG
Authorized Official - Suffix:
Authorized Official - Credentials:DO, FAO,CO
Authorized Official - Phone:586-412-0900
Mailing Address - Street 1:17901 HALL RD
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:MI
Mailing Address - Zip Code:48044-4557
Mailing Address - Country:US
Mailing Address - Phone:586-412-0900
Mailing Address - Fax:586-412-9762
Practice Address - Street 1:17901 HALL RD
Practice Address - Street 2:
Practice Address - City:MACOMB
Practice Address - State:MI
Practice Address - Zip Code:48044-4557
Practice Address - Country:US
Practice Address - Phone:586-412-0900
Practice Address - Fax:586-412-9762
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-20
Last Update Date:2012-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIRC011400207Y00000X, 207YX0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
No207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic SurgeryGroup - Single Specialty