Provider Demographics
NPI:1275952020
Name:SUNDBY, RUSSELL TAYLOR (MD)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:TAYLOR
Last Name:SUNDBY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:TAYLOR
Other - Middle Name:
Other - Last Name:SUNDBY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1800 ORLEANS ST RM 11379
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21287-0010
Mailing Address - Country:US
Mailing Address - Phone:410-955-8751
Mailing Address - Fax:410-955-0028
Practice Address - Street 1:1800 ORLEANS ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21287
Practice Address - Country:US
Practice Address - Phone:410-955-8751
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-09
Last Update Date:2018-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA142969208000000X
MD390200000X
MDD0085726208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program