Provider Demographics
NPI:1891730693
Name:BUTKIEWICZ, RUSSELL F (MD)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:F
Last Name:BUTKIEWICZ
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 1:3 NEENAH CTR
Mailing Address - Street 2:
Mailing Address - City:NEENAH
Mailing Address - State:WI
Mailing Address - Zip Code:54956-3070
Mailing Address - Country:US
Mailing Address - Phone:715-256-3000
Mailing Address - Fax:715-256-3079
Practice Address - Street 1:710 RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:WAUPACA
Practice Address - State:WI
Practice Address - Zip Code:54981-1941
Practice Address - Country:US
Practice Address - Phone:715-256-3000
Practice Address - Fax:715-256-3079
Is Sole Proprietor?:No
Enumeration Date:2006-06-17
Last Update Date:2021-07-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI29613207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI080102084OtherRAILROAD MEDICARE
WI31622900Medicaid
WI31622900Medicaid
000569010Medicare ID - Type Unspecified
E50665Medicare UPIN