Provider Demographics
NPI:1972596823
Name:LAWSON, RUSSELL K (MD)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:K
Last Name:LAWSON
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 1:1601 GOLF COURSE ROAD
Mailing Address - Street 2:GRAND ITASCA CLINIC & HOSPITAL
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55744
Mailing Address - Country:US
Mailing Address - Phone:218-326-5000
Mailing Address - Fax:218-999-1461
Practice Address - Street 1:1601 GOLF COURSE ROAD
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55744
Practice Address - Country:US
Practice Address - Phone:218-326-5000
Practice Address - Fax:218-999-1461
Is Sole Proprietor?:No
Enumeration Date:2005-08-25
Last Update Date:2012-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI20043208800000X
MN49175208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30156600Medicaid
WI30156600Medicaid
WI000168900Medicare ID - Type Unspecified
B54481Medicare UPIN