Provider Demographics
NPI:1801818489
Name:HJELMSTAD, RUSSELL HOWARD (MD)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:HOWARD
Last Name:HJELMSTAD
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 1:1105 6TH ST
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-2345
Mailing Address - Country:US
Mailing Address - Phone:231-935-0499
Mailing Address - Fax:
Practice Address - Street 1:1105 6TH ST
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-2345
Practice Address - Country:US
Practice Address - Phone:231-935-0499
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2007-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301060645207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2918219Medicaid
MI2918219Medicaid