Provider Demographics
NPI:1093767774
Name:RUSSELL, ELIZABETH B (MD)
Entity type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:B
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:885 N SANDUSKY AVE
Mailing Address - Street 2:
Mailing Address - City:UPPER SANDUSKY
Mailing Address - State:OH
Mailing Address - Zip Code:43351-1098
Mailing Address - Country:US
Mailing Address - Phone:262-515-3040
Mailing Address - Fax:419-209-0278
Practice Address - Street 1:885 N SANDUSKY AVE
Practice Address - Street 2:
Practice Address - City:UPPER SANDUSKY
Practice Address - State:OH
Practice Address - Zip Code:43351-1098
Practice Address - Country:US
Practice Address - Phone:419-294-4991
Practice Address - Fax:419-294-4750
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2020-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI27065207RR0500X
ARE-6331207RR0500X
OH35138914207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30686300Medicaid
WI81018OtherDEAN S.E MEDICAID
WI81018OtherCHILDRENS COMM. HEALTH
WI1058858001OtherDIAMOND PROVIDER ID
OH0394617Medicaid
WI$$$$$$$$$002OtherBLUE CROSS BLUE SHIELD
WI81018OtherCHILDRENS COMM. HEALTH
AR5AA95Medicare PIN