Healthcare Provider Details

I. General information

NPI: 1043245277
Provider Name (Legal Business Name): RUSSELL PETTY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HIGHWAY 281 NORTH
CANDO ND
58324-0688
US

IV. Provider business mailing address

PO BOX 688
CANDO ND
58324-0688
US

V. Phone/Fax

Practice location:
  • Phone: 701-968-2541
  • Fax: 701-968-2574
Mailing address:
  • Phone: 701-968-2541
  • Fax: 701-968-2574

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number3895
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: