Healthcare Provider Details

I. General information

NPI: 1104771526
Provider Name (Legal Business Name): BOHDAN RUSSUM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/02/2026
Last Update Date: 03/02/2026
Certification Date: 03/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 CROWN POINT CIR
GRASS VALLEY CA
95945-9561
US

IV. Provider business mailing address

10560 KEARNEY CT
SMARTSVILLE CA
95977-9556
US

V. Phone/Fax

Practice location:
  • Phone: 415-847-8420
  • Fax:
Mailing address:
  • Phone: 415-847-8420
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: