Provider Demographics
NPI:1417241415
Name:RUSSELL, SARAH FULHAM (MD)
Entity type:Individual
Prefix:
First Name:SARAH
Middle Name:FULHAM
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:57 PROSPECT ST
Mailing Address - Street 2:
Mailing Address - City:NANTUCKET
Mailing Address - State:MA
Mailing Address - Zip Code:02554-2799
Mailing Address - Country:US
Mailing Address - Phone:508-825-8100
Mailing Address - Fax:
Practice Address - Street 1:57 PROSPECT ST
Practice Address - Street 2:
Practice Address - City:NANTUCKET
Practice Address - State:MA
Practice Address - Zip Code:02554-2799
Practice Address - Country:US
Practice Address - Phone:508-825-8100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-07
Last Update Date:2024-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI65857-20207R00000X
MA1021381207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1417241415Medicaid
WIK400336831Medicare PIN