Provider Demographics
NPI:1912993437
Name:RUSS, ANDREW B (MD)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:B
Last Name:RUSS
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 1:24 MILES CENTER WAY
Mailing Address - Street 2:
Mailing Address - City:DAMARISCOTTA
Mailing Address - State:ME
Mailing Address - Zip Code:04543-4047
Mailing Address - Country:US
Mailing Address - Phone:207-563-4250
Mailing Address - Fax:207-563-4246
Practice Address - Street 1:24 MILES CENTER WAY
Practice Address - Street 2:
Practice Address - City:DAMARISCOTTA
Practice Address - State:ME
Practice Address - Zip Code:04543-4047
Practice Address - Country:US
Practice Address - Phone:207-563-4250
Practice Address - Fax:207-563-4246
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2018-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME016854208000000X
MEMD16854208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics