Provider Demographics
NPI:1225008501
Name:RUSS, ROBERT MICHAEL (MD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:MICHAEL
Last Name:RUSS
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6101 BLUE LAGOON DR STE 200
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33126-3168
Mailing Address - Country:US
Mailing Address - Phone:725-220-8457
Mailing Address - Fax:833-749-0355
Practice Address - Street 1:3129 N RAINBOW BLVD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89108-4578
Practice Address - Country:US
Practice Address - Phone:725-220-8457
Practice Address - Fax:833-749-0355
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2025-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301068622207R00000X
NV18194207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1225008501Medicaid
NV18194OtherSTATE LICENSE
MI4184668Medicaid