Provider Demographics
NPI:1699751420
Name:RUSS, JOHN ALBERT III (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:ALBERT
Last Name:RUSS
Suffix:III
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 1:5500 LARCHWOOD LN
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43614-1249
Mailing Address - Country:US
Mailing Address - Phone:419-867-0132
Mailing Address - Fax:
Practice Address - Street 1:5500 LARCHWOOD LN
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43614-1249
Practice Address - Country:US
Practice Address - Phone:419-867-0132
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2011-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH46437207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000372037OtherBLUE CROSS BLUE SHIELD
OHP00306243OtherRAILROAD MEDICARE
OH000000387472OtherBLUE CROSS BLUE SHIELD
OHP00290081OtherRAILROAD MEDICARE
OHRU0737674Medicare PIN
OH000000387472OtherBLUE CROSS BLUE SHIELD