Provider Demographics
NPI:1932178241
Name:RUSSELL, GEORGE R (MD)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:R
Last Name:RUSSELL
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:PO BOX 18058
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80308-1058
Mailing Address - Country:US
Mailing Address - Phone:303-444-4864
Mailing Address - Fax:303-444-4865
Practice Address - Street 1:1000 ALPINE AVE
Practice Address - Street 2:#50
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80304-3409
Practice Address - Country:US
Practice Address - Phone:303-444-4864
Practice Address - Fax:303-444-4865
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2008-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO17600207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO840721166001OtherROCKY MOUNTAIN
CORU78831OtherBLUE CROSS
CO84072116601OtherPACIFICARE
CO01176007Medicaid
CO4009828OtherAETNA
CO667695OtherBCBS FEDERAL
COC811805Medicare PIN
CO84072116601OtherPACIFICARE
CO667695OtherBCBS FEDERAL