Provider Demographics
NPI:1265599773
Name:RASKIN, RUSSELL W (MD)
Entity type:Individual
Prefix:
First Name:RUSSELL
Middle Name:W
Last Name:RASKIN
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:PO BOX 1470
Mailing Address - Street 2:
Mailing Address - City:PORT WASHINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11050-7470
Mailing Address - Country:US
Mailing Address - Phone:516-629-2454
Mailing Address - Fax:516-629-2027
Practice Address - Street 1:100 PORT WASHINGTON BLVD
Practice Address - Street 2:DEPT. OF EMERGENCY MEDICINE
Practice Address - City:ROSLYN
Practice Address - State:NY
Practice Address - Zip Code:11576-1353
Practice Address - Country:US
Practice Address - Phone:516-562-6605
Practice Address - Fax:516-629-2027
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2020-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2147091207PE0004X
NY214709207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02393873Medicaid
NY868V31Medicare ID - Type Unspecified
NY02393873Medicaid