Provider Demographics
NPI:1306976717
Name:ELKHART NEUROLOGY PC
Entity type:Organization
Organization Name:ELKHART NEUROLOGY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:W
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:574-522-7624
Mailing Address - Street 1:2746 OLD US 20 W
Mailing Address - Street 2:SUITE A
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46514-1364
Mailing Address - Country:US
Mailing Address - Phone:574-522-7624
Mailing Address - Fax:574-522-9405
Practice Address - Street 1:2746 OLD US 20 W
Practice Address - Street 2:SUITE A
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-1364
Practice Address - Country:US
Practice Address - Phone:574-522-7624
Practice Address - Fax:574-522-9405
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-06
Last Update Date:2008-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN020012192084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100114080BMedicaid
IN100114080BMedicaid
IN186120AMedicare PIN