Healthcare Provider Details

I. General information

NPI: 1831201334
Provider Name (Legal Business Name): FERN GILDA RUSSAK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3550 N INTERSTATE AVE
PORTLAND OR
97227-1196
US

IV. Provider business mailing address

938 NE HAZELFERN PL
PORTLAND OR
97232-2628
US

V. Phone/Fax

Practice location:
  • Phone: 503-285-9321
  • Fax:
Mailing address:
  • Phone: 503-331-6440
  • Fax: 503-239-5486

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD24761
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD00044048
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberG64232
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: