Provider Demographics
NPI:1992813174
Name:RUSSELL, ROBERT T (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:T
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 1:1404 EASTLAND DR STE 209
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-7904
Mailing Address - Country:US
Mailing Address - Phone:309-662-3277
Mailing Address - Fax:309-663-0845
Practice Address - Street 1:1404 EASTLAND DR STE 209
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-7904
Practice Address - Country:US
Practice Address - Phone:309-662-3277
Practice Address - Fax:309-663-0845
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-28
Last Update Date:2015-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036082417207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
05700224OtherBLU CROSS BLUE SHIELD
IL036082417Medicaid
F76969Medicare UPIN
341330Medicare ID - Type Unspecified
K46938Medicare PIN