Provider Demographics
NPI:1891724167
Name:DILLEY, RUSSELL S (MD)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:S
Last Name:DILLEY
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 1:6626 E 75TH ST
Mailing Address - Street 2:SUITE 500
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2805
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1400 N RITTER AVE
Practice Address - Street 2:SUITE # 520
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46219-3052
Practice Address - Country:US
Practice Address - Phone:317-355-1234
Practice Address - Fax:317-355-1505
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2017-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN010266462086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP01214606OtherRR MEDICARE PTAN
IN100064180AMedicaid
INP00719539Medicare PIN
IN060660AMedicare PIN
INP01214606OtherRR MEDICARE PTAN
IN266180138Medicare PIN
IN251320VMedicare PIN