Provider Demographics
NPI:1912976085
Name:CARTER, RUSSELL W (DO)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:W
Last Name:CARTER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2605 KENTUCKY AVE
Mailing Address - Street 2:SUITE 306
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42003-3800
Mailing Address - Country:US
Mailing Address - Phone:270-415-4690
Mailing Address - Fax:270-415-4691
Practice Address - Street 1:2605 KENTUCKY AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42003-3800
Practice Address - Country:US
Practice Address - Phone:270-415-4690
Practice Address - Fax:270-415-4691
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036102415207RG0100X
KY02476207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64024763Medicaid
KY64024763Medicaid
KYK167920Medicare PIN
ILL82440Medicare ID - Type Unspecified