Provider Demographics
NPI:1891377685
Name:RUSSELL, ASHLEY ROSEMAE (MD)
Entity type:Individual
Prefix:
First Name:ASHLEY
Middle Name:ROSEMAE
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 1:419 E. PERKINS AVENUE
Mailing Address - Street 2:
Mailing Address - City:SANDUSKY
Mailing Address - State:OH
Mailing Address - Zip Code:44870
Mailing Address - Country:US
Mailing Address - Phone:419-557-7455
Mailing Address - Fax:419-557-7782
Practice Address - Street 1:419 E. PERKINS AVENUE
Practice Address - Street 2:
Practice Address - City:SANDUSKY
Practice Address - State:OH
Practice Address - Zip Code:44870
Practice Address - Country:US
Practice Address - Phone:419-557-7455
Practice Address - Fax:419-557-7782
Is Sole Proprietor?:No
Enumeration Date:2021-04-22
Last Update Date:2024-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.146812207P00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH35.146812OtherOH MEDICAL LICENSE
OH0443102Medicaid