Provider Demographics
NPI:1962500181
Name:RUSSELL B CALDWELL MD PC
Entity Type:Organization
Organization Name:RUSSELL B CALDWELL MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:B
Authorized Official - Last Name:CALDWELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:425-454-7546
Mailing Address - Street 1:1810 116TH AVE NE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98004-3058
Mailing Address - Country:US
Mailing Address - Phone:425-455-2276
Mailing Address - Fax:425-455-1511
Practice Address - Street 1:1810 116TH AVE NE
Practice Address - Street 2:SUITE 100
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-3058
Practice Address - Country:US
Practice Address - Phone:425-455-2276
Practice Address - Fax:425-455-1511
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2011-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00015594207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAGAB29474Medicare PIN