Provider Demographics
NPI:1285610170
Name:RUSSEK, FREDRICK (MD)
Entity type:Individual
Prefix:
First Name:FREDRICK
Middle Name:
Last Name:RUSSEK
Suffix:
Gender:M
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:PO BOX 10966
Mailing Address - Street 2:SUITE 101
Mailing Address - City:FORT MOHAVE
Mailing Address - State:AZ
Mailing Address - Zip Code:86427-0966
Mailing Address - Country:US
Mailing Address - Phone:928-788-3333
Mailing Address - Fax:928-788-3555
Practice Address - Street 1:5263 S HIGHWAY 95
Practice Address - Street 2:SUITE 101
Practice Address - City:FORT MOHAVE
Practice Address - State:AZ
Practice Address - Zip Code:86426-9223
Practice Address - Country:US
Practice Address - Phone:928-788-3333
Practice Address - Fax:928-788-3555
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-21
Last Update Date:2014-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV582207L00000X
AZ2202207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002002781Medicaid
AZ256661Medicaid
AZB47511Medicare UPIN
AZ256661Medicaid
NV002002781Medicaid