Provider Demographics
NPI:1992918551
Name:RUSSEL PARDOE, M.D., INC.
Entity type:Organization
Organization Name:RUSSEL PARDOE, M.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RUSSEL
Authorized Official - Middle Name:
Authorized Official - Last Name:PARDOE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:707-445-3075
Mailing Address - Street 1:2752 HARRISON AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:EUREKA
Mailing Address - State:CA
Mailing Address - Zip Code:95501-4738
Mailing Address - Country:US
Mailing Address - Phone:707-445-3075
Mailing Address - Fax:707-445-3076
Practice Address - Street 1:2752 HARRISON AVE
Practice Address - Street 2:SUITE A
Practice Address - City:EUREKA
Practice Address - State:CA
Practice Address - Zip Code:95501-4738
Practice Address - Country:US
Practice Address - Phone:707-445-3075
Practice Address - Fax:707-445-3076
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-08
Last Update Date:2008-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0093660Medicaid
CAGR0093660Medicaid