Provider Demographics
NPI:1386795326
Name:BERSCHEID, RUSSELL J (MD)
Entity type:Individual
Prefix:
First Name:RUSSELL
Middle Name:J
Last Name:BERSCHEID
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 229
Mailing Address - Street 2:
Mailing Address - City:WAKEFIELD
Mailing Address - State:RI
Mailing Address - Zip Code:02880-0229
Mailing Address - Country:US
Mailing Address - Phone:401-788-8757
Mailing Address - Fax:
Practice Address - Street 1:1218 TROTWOOD AVE
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:TN
Practice Address - Zip Code:38401-6406
Practice Address - Country:US
Practice Address - Phone:931-540-4140
Practice Address - Fax:931-540-4143
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2019-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN28088207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3804626Medicaid
TN3732438Medicaid
TN4114051OtherBCBS TN
TN3804626Medicaid
TN3732438Medicaid
TN3732438Medicare PIN
TNDE2565Medicare PIN
TN3804626Medicare PIN