Provider Demographics
NPI:1669519765
Name:GREIF, RUSSELL M (DO)
Entity type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:M
Last Name:GREIF
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2010 W AVENUE K # 632
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93536-5229
Mailing Address - Country:US
Mailing Address - Phone:661-726-6490
Mailing Address - Fax:661-726-6494
Practice Address - Street 1:44241 15TH ST W
Practice Address - Street 2:SUITE 206
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534-4037
Practice Address - Country:US
Practice Address - Phone:661-726-6490
Practice Address - Fax:661-726-6494
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2011-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A5410207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA020A54100Medicaid
CA954483182OtherBLUE CROSS
CADOAX54100Medicaid
CA020A54100OtherBLUE SHIELD
CA954483182OtherBLUE CROSS
CAE58959Medicare UPIN
CA20A5410Medicare PIN