Provider Demographics
NPI:1154355477
Name:STRUBLE, RUSSELL J (MD)
Entity type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:J
Last Name:STRUBLE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:200 S WENONA ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BAY CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48706-8820
Mailing Address - Country:US
Mailing Address - Phone:989-892-6587
Mailing Address - Fax:989-892-3140
Practice Address - Street 1:200 S WENONA ST
Practice Address - Street 2:SUITE 100
Practice Address - City:BAY CITY
Practice Address - State:MI
Practice Address - Zip Code:48706-8820
Practice Address - Country:US
Practice Address - Phone:989-892-6587
Practice Address - Fax:989-892-3140
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2011-10-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MIRS068547207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIRS068547OtherBCR LICENSE NUMBER
MI4115114Medicaid
MIRS068547OtherBCR LICENSE NUMBER
MIG86122Medicare ID - Type Unspecified