Healthcare Provider Details

I. General information

NPI: 1275692030
Provider Name (Legal Business Name): KATHY J RUSSETH M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/07/2006
Last Update Date: 10/04/2024
Certification Date: 10/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

345 W WASHINGTON AVE STE 307
MADISON WI
53703-6019
US

IV. Provider business mailing address

345 W WASHINGTON AVE STE 307
MADISON WI
53703-6019
US

V. Phone/Fax

Practice location:
  • Phone: 414-395-5435
  • Fax:
Mailing address:
  • Phone: 608-305-4150
  • Fax: 608-305-8736

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number49950-020
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number49950-020
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: