Provider Demographics
NPI:1962479071
Name:WAVRIN, RUSSELL L (MD)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:L
Last Name:WAVRIN
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 1:6545 FRANCE AVE S
Mailing Address - Street 2:STE 540
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-2131
Mailing Address - Country:US
Mailing Address - Phone:952-927-4045
Mailing Address - Fax:952-924-4133
Practice Address - Street 1:6545 FRANCE AVE S
Practice Address - Street 2:STE 540
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-2131
Practice Address - Country:US
Practice Address - Phone:952-927-4045
Practice Address - Fax:952-924-4133
Is Sole Proprietor?:No
Enumeration Date:2006-03-07
Last Update Date:2016-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN244196207V00000X, 207VE0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No207VE0102XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyReproductive Endocrinology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN18559WAOtherBCBS
MNHP14652OtherHEALTHPARTNERS
MN055302600Medicaid
MNHP14652OtherHEALTHPARTNERS
160000055Medicare ID - Type Unspecified