Healthcare Provider Details

I. General information

NPI: 1700564382
Provider Name (Legal Business Name): KATHY J. RUSSETH, M.D., S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/05/2023
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 Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. KATHY J RUSSETH
Title or Position: PRESIDENT
Credential: MD
Phone: 608-305-4150