Provider Demographics
NPI:1962495846
Name:RUSSELL, SARAH (AA)
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:AA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3605 WARRENSVILLE CENTER ROAD
Mailing Address - Street 2:1ST FLOOR
Mailing Address - City:SHAKER HTS
Mailing Address - State:OH
Mailing Address - Zip Code:44122
Mailing Address - Country:US
Mailing Address - Phone:216-286-6260
Mailing Address - Fax:216-286-6341
Practice Address - Street 1:11100 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44106
Practice Address - Country:US
Practice Address - Phone:216-844-7330
Practice Address - Fax:216-844-3781
Is Sole Proprietor?:No
Enumeration Date:2005-08-26
Last Update Date:2009-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH67000095367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH415029OtherWELLCARE MEDICAID
OH0583328OtherBCMH
OH7669949OtherAETNA
OH000000232320OtherUNISON
OH000000521138OtherANTHEM
OH2517459Medicaid
OH2517459Medicaid