Healthcare Provider Details

I. General information

NPI: 1093789372
Provider Name (Legal Business Name): SCOTT ANDREW RUSSI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/14/2006
Last Update Date: 06/08/2022
Certification Date: 04/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 NE 87TH AVE STE 301
VANCOUVER WA
98664-1965
US

IV. Provider business mailing address

85182 BLUE HERON WAY
EUGENE OR
97405-8671
US

V. Phone/Fax

Practice location:
  • Phone: 360-514-7374
  • Fax: 360-514-7384
Mailing address:
  • Phone: 719-243-6631
  • Fax: 541-868-9306

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD61007212
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMD163726
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number4748
License Number StateAK
# 4
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMD61007212
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: