Provider Demographics
NPI:1790789543
Name:PIETZ, RUSSELL C (MD)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:C
Last Name:PIETZ
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 1:305 S STATE ST
Mailing Address - Street 2:
Mailing Address - City:ABERDEEN
Mailing Address - State:SD
Mailing Address - Zip Code:57401-4527
Mailing Address - Country:US
Mailing Address - Phone:605-622-5100
Mailing Address - Fax:605-622-4030
Practice Address - Street 1:305 S STATE ST
Practice Address - Street 2:
Practice Address - City:ABERDEEN
Practice Address - State:SD
Practice Address - Zip Code:57401-4527
Practice Address - Country:US
Practice Address - Phone:605-622-5100
Practice Address - Fax:605-622-4030
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2016-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD4105207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD6003203Medicaid
SD6003202Medicaid
ND11631Medicaid
ND11631Medicaid
SD6003203Medicaid
S8120Medicare PIN