Provider Demographics
NPI:1932194545
Name:GELORMINI, RUSSELL GERALD (DO)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:GERALD
Last Name:GELORMINI
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 1:11995 SINGLETREE LN
Mailing Address - Street 2:STE 500
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55344-5347
Mailing Address - Country:US
Mailing Address - Phone:952-595-1301
Mailing Address - Fax:612-294-4903
Practice Address - Street 1:27817 LEGACY WOODS
Practice Address - Street 2:
Practice Address - City:BOERNE
Practice Address - State:TX
Practice Address - Zip Code:78015-4995
Practice Address - Country:US
Practice Address - Phone:952-595-1100
Practice Address - Fax:612-294-4903
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2016-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS92832085R0202X
TXP05902085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU4663YMedicare PIN
FL000902400Medicaid
FLU4663AMedicare ID - Type Unspecified
SCQS9293Medicaid
PA1021342300001Medicaid
FLU4663ZMedicare PIN
FLU4663VMedicare PIN
I28725Medicare UPIN