Provider Demographics
NPI:1992775456
Name:RUSSELL, CALVIN (MD)
Entity type:Individual
Prefix:
First Name:CALVIN
Middle Name:
Last Name:RUSSELL
Suffix:
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 1:1391 N BALDWIN AVE
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IN
Mailing Address - Zip Code:46952-1913
Mailing Address - Country:US
Mailing Address - Phone:765-662-2534
Mailing Address - Fax:
Practice Address - Street 1:1391 N BALDWIN AVE
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IN
Practice Address - Zip Code:46952-1913
Practice Address - Country:US
Practice Address - Phone:765-662-2534
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01024365207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IND94748Medicare UPIN
IN215750BMedicare ID - Type Unspecified