Provider Demographics
NPI:1245414093
Name:RUSSELL, MICHAEL
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:MICHAEL RUSSELL DBA
Other - Middle Name:
Other - Last Name:TODD TRANSIT COMPANY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:4588 N 23RD ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53209-6201
Mailing Address - Country:US
Mailing Address - Phone:414-477-4978
Mailing Address - Fax:414-445-1515
Practice Address - Street 1:4588 N 23RD ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53209-6201
Practice Address - Country:US
Practice Address - Phone:414-477-4978
Practice Address - Fax:414-445-1515
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-27
Last Update Date:2007-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI41487100343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41487100Medicaid