Provider Demographics
NPI:1811007966
Name:WILKE, RUSSELL A (MD)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:A
Last Name:WILKE
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 5074
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5074
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1205 S GRANGE AVE
Practice Address - Street 2:STE 510
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-0407
Practice Address - Country:US
Practice Address - Phone:605-328-7500
Practice Address - Fax:605-328-7599
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2016-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI38145207R00000X
TN45694207R00000X
MN42291207R00000X
ND12805207R00000X
SD9764207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1519301Medicaid
WI32289100Medicaid
ND18144Medicaid
WI32289100Medicaid
MN110016245Medicare UPIN
G37286Medicare UPIN
NDN719215Medicare UPIN
TN1519301Medicaid
TN103I111056Medicare PIN
WI73172200Medicare ID - Type Unspecified