Provider Demographics
NPI:1851301253
Name:RUSSELL, ELIZABETH JOYCE (MD)
Entity Type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:JOYCE
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 22487
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54305-2487
Mailing Address - Country:US
Mailing Address - Phone:920-445-7210
Mailing Address - Fax:920-445-7289
Practice Address - Street 1:820 ARBUTUS AVE
Practice Address - Street 2:
Practice Address - City:OCONTO
Practice Address - State:WI
Practice Address - Zip Code:54153-2004
Practice Address - Country:US
Practice Address - Phone:920-835-1100
Practice Address - Fax:920-835-1099
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2020-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI37344207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
537527OtherAMERICAN BOARD OF FAMILY MEDICINE
WI1851477913OtherCMH NPI
WI32194900Medicaid
WI11014110Medicaid
WIF61568Medicare UPIN
WI32194900Medicaid
WIK400134386Medicare Oscar/Certification
WI52Z310Medicare Oscar/Certification
WI075100054Medicare Oscar/Certification