Provider Demographics
NPI:1104823475
Name:RUSSELL, W RANDALL (MD)
Entity type:Individual
Prefix:DR
First Name:W
Middle Name:RANDALL
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:100 E LANCASTER AVE
Mailing Address - Street 2:SUITE 151 LANKENAU MOB EAST
Mailing Address - City:WYNNEWOOD
Mailing Address - State:PA
Mailing Address - Zip Code:19096-3450
Mailing Address - Country:US
Mailing Address - Phone:484-476-6492
Mailing Address - Fax:484-476-8147
Practice Address - Street 1:100 E LANCASTER AVE
Practice Address - Street 2:SUITE 151 LANKENAU MOB EAST
Practice Address - City:WYNNEWOOD
Practice Address - State:PA
Practice Address - Zip Code:19096-3450
Practice Address - Country:US
Practice Address - Phone:484-476-6492
Practice Address - Fax:484-476-8147
Is Sole Proprietor?:No
Enumeration Date:2005-07-01
Last Update Date:2015-03-27
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Provider Licenses
StateLicense IDTaxonomies
PAMD032388E208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
E13063Medicare UPIN
PA001850468-002Medicaid
PA641190J6SMedicare ID - Type UnspecifiedGROUP NUMBER
PA558570Medicare ID - Type Unspecified
PA558570HK1Medicare PIN