Provider Demographics
NPI:1346099132
Name:RUSS, BLAINE BURKE (MD)
Entity type:Individual
Prefix:
First Name:BLAINE
Middle Name:BURKE
Last Name:RUSS
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 1:36 SANDY BROOK LN
Mailing Address - Street 2:
Mailing Address - City:CASTLE CREEK
Mailing Address - State:NY
Mailing Address - Zip Code:13744-1123
Mailing Address - Country:US
Mailing Address - Phone:607-644-2143
Mailing Address - Fax:
Practice Address - Street 1:150 BERGEN ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07103-2496
Practice Address - Country:US
Practice Address - Phone:973-972-4300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-15
Last Update Date:2024-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program