Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207RN0300X | Nephrologist | 26461 | MN |
NPI | 1023046570 |
---|---|
Provider Name | Thomas Edward Russ |
First Address | Duluth, MN 55805-1951 |
Second Address | Duluth, MN 55805-1951 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 30/06/2006 |
Last Update Date | 09/05/2011 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
550705700 | (05) | MN |
D75831 | (02) |