Healthcare Provider Details

I. General information

NPI: 1275522039
Provider Name (Legal Business Name): RUSSELL DAUGHERTY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/14/2005
Last Update Date: 02/17/2025
Certification Date: 02/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 N MAIN ST
RUSHVILLE IN
46173-1198
US

IV. Provider business mailing address

1300 N MAIN ST
RUSHVILLE IN
46173-1198
US

V. Phone/Fax

Practice location:
  • Phone: 765-932-7439
  • Fax: 765-932-7410
Mailing address:
  • Phone: 765-932-4111
  • Fax: 765-932-7505

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number01042648A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number01042648A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number01042648A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: