Provider Demographics
NPI:1831279223
Name:VANHOUZEN, RUSSELL NEIL (MD)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:NEIL
Last Name:VANHOUZEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10161 E PICKWICK CT
Mailing Address - Street 2:SUITE E
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-5239
Mailing Address - Country:US
Mailing Address - Phone:231-935-0888
Mailing Address - Fax:231-935-0890
Practice Address - Street 1:10161 E PICKWICK CT
Practice Address - Street 2:SUITE E
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-5239
Practice Address - Country:US
Practice Address - Phone:231-935-0888
Practice Address - Fax:231-935-0890
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301035319207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1096875Medicaid
MI1102810212OtherBLUE CROSS