Provider Demographics
NPI:1316914120
Name:FITZGERALD, RUSSELL W (MD)
Entity type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:W
Last Name:FITZGERALD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2 PLAZA DR
Mailing Address - Street 2:
Mailing Address - City:LIBERAL
Mailing Address - State:KS
Mailing Address - Zip Code:67901-2743
Mailing Address - Country:US
Mailing Address - Phone:620-624-5691
Mailing Address - Fax:620-624-3656
Practice Address - Street 1:2 PLAZA DR
Practice Address - Street 2:
Practice Address - City:LIBERAL
Practice Address - State:KS
Practice Address - Zip Code:67901-2743
Practice Address - Country:US
Practice Address - Phone:620-624-5691
Practice Address - Fax:620-624-3656
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-27378207R00000X
OK23365207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS101857OtherBCBS OF KS
KSG91727Medicare UPIN
KS101857OtherBCBS OF KS