Provider Demographics
NPI:1881663078
Name:ALLISON, RUSSELL B (MD)
Entity Type:Individual
Prefix:MR
First Name:RUSSELL
Middle Name:B
Last Name:ALLISON
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 1:1400 W 4TH ST
Mailing Address - Street 2:
Mailing Address - City:COFFEYVILLE
Mailing Address - State:KS
Mailing Address - Zip Code:67337-3306
Mailing Address - Country:US
Mailing Address - Phone:620-252-1639
Mailing Address - Fax:620-252-1541
Practice Address - Street 1:1400 W 4TH ST
Practice Address - Street 2:
Practice Address - City:COFFEYVILLE
Practice Address - State:KS
Practice Address - Zip Code:67337-3306
Practice Address - Country:US
Practice Address - Phone:620-252-1639
Practice Address - Fax:620-252-1541
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2019-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0442302207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR124670001Medicaid
AR200032041OtherPALMETTO MEDICARE RAILROAD
AR1274700001Medicare NSC
F71373Medicare UPIN
AR5J277Medicare ID - Type Unspecified