Provider Demographics
NPI:1881746345
Name:RUSSELL, HUGH DONOVAN (MD)
Entity type:Individual
Prefix:DR
First Name:HUGH
Middle Name:DONOVAN
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:HUGH
Other - Middle Name:DONOVAN
Other - Last Name:RUSSELL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:8501 S COTTAGE GROVE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60619
Mailing Address - Country:US
Mailing Address - Phone:773-488-3600
Mailing Address - Fax:773-488-3601
Practice Address - Street 1:8501 S COTTAGE GROVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60619
Practice Address - Country:US
Practice Address - Phone:773-488-3600
Practice Address - Fax:773-488-3601
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2008-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036064027207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036034027Medicaid
AR1594262OtherUS GOFT DEPT OF EDU RES D
D15163Medicare UPIN
AR1594262OtherUS GOFT DEPT OF EDU RES D