Healthcare Provider Details

I. General information

NPI: 1629239355
Provider Name (Legal Business Name): STEPHANIE JANE RUSS DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: STEPHANIE JANE WILSON DO

II. Dates (important events)

Enumeration Date: 06/25/2008
Last Update Date: 10/09/2025
Certification Date: 10/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 ENTERPRISE DR STE A
PENDLETON IN
46064-9038
US

IV. Provider business mailing address

6626 E 75TH ST STE 500
INDIANAPOLIS IN
46250-2890
US

V. Phone/Fax

Practice location:
  • Phone: 765-298-4567
  • Fax:
Mailing address:
  • Phone: 765-298-4569
  • Fax: 765-298-4568

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number11014474A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: