Provider Demographics
NPI:1396789194
Name:MAULITZ, RUSSELL CHARLES (MD)
Entity type:Individual
Prefix:
First Name:RUSSELL
Middle Name:CHARLES
Last Name:MAULITZ
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 1:210 S 25TH ST UNIT 606
Mailing Address - Street 2:SUITE 606
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19103-5876
Mailing Address - Country:US
Mailing Address - Phone:215-805-6915
Mailing Address - Fax:
Practice Address - Street 1:210 S 25TH ST UNIT 606
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19103-5876
Practice Address - Country:US
Practice Address - Phone:215-805-6915
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-15
Last Update Date:2024-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD017259E207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA000662893Medicaid
PAB36195Medicare UPIN