Provider Demographics
NPI:1548318793
Name:WILLIAMS, RUSSELL G (DO)
Entity type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:G
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 GLOCHESKI DR
Mailing Address - Street 2:
Mailing Address - City:MANISTEE
Mailing Address - State:MI
Mailing Address - Zip Code:49660-2639
Mailing Address - Country:US
Mailing Address - Phone:877-398-2013
Mailing Address - Fax:
Practice Address - Street 1:395 3RD ST
Practice Address - Street 2:
Practice Address - City:MANISTEE
Practice Address - State:MI
Practice Address - Zip Code:49660-1718
Practice Address - Country:US
Practice Address - Phone:877-398-2013
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-06
Last Update Date:2009-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI51010165942084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIE16001022OtherMEDICARE PTAN
MI0E16001OtherMEDICARE GROUP PTAN
MI4782586Medicaid
MIRW016594OtherSTATE LICENSE NUMBER
I00338Medicare UPIN
MI4782586Medicaid