Provider Demographics
NPI:1760414916
Name:RUSSELL, KRAIG M (MD)
Entity Type:Individual
Prefix:
First Name:KRAIG
Middle Name:M
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:PO BOX 92900
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97292-0900
Mailing Address - Country:US
Mailing Address - Phone:503-261-6985
Mailing Address - Fax:503-261-6790
Practice Address - Street 1:10123 SE MARKET ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97216-2532
Practice Address - Country:US
Practice Address - Phone:503-261-6985
Practice Address - Fax:503-261-6790
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35087067207R00000X
NC200900320207R00000X, 207RH0002X
ORMD156766207RH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2663069Medicaid
NC5911521Medicaid
OHI60664Medicare UPIN
NC2073348Medicare PIN
OHRU7359611Medicare PIN