Provider Demographics
NPI:1588865646
Name:GEORGE RAY RUSSELL MD PC
Entity type:Organization
Organization Name:GEORGE RAY RUSSELL MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:R
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:303-444-4864
Mailing Address - Street 1:PO BOX 18058
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80308-1058
Mailing Address - Country:US
Mailing Address - Phone:303-444-4864
Mailing Address - Fax:303-444-4865
Practice Address - Street 1:1000 ALPINE AVE
Practice Address - Street 2:#50
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80304-3409
Practice Address - Country:US
Practice Address - Phone:303-444-4864
Practice Address - Fax:303-444-4865
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-29
Last Update Date:2008-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO17600207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO84307366Medicaid
COGE667695OtherBCBS OF CO GROUP #
COGE667695OtherBCBS OF CO GROUP #