MEDICARE: EVAN T RUSSELL MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208M00000X	Hospitalist Physician	01068153A	IN
2	207RI0011X	Interventional Cardiology Physician	01068153A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1609039973
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EVAN T RUSSELL MD

Provider Business Mailing Address
First Line	:	PO BOX 775383
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60677-5383
Country	:	US
Telephone Number	:	812-376-5315
Fax Number	:

Provider Business Practice Location Address
First Line	:	2325 18TH ST
Second Line	:	SUITE 130
City	:	COLUMBUS
State	:	IN
Zip	:	47201-5388
Country	:	US
Telephone Number	:	812-379-2020
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/08/2008
Last Update Date	:	09/06/2024

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Directions to “ EVAN T RUSSELL MD” Practice Location

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