Basic Information
| Provider Information | |||||||||
| NPI: | 1023022696 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NILES | ||||||||
| FirstName: | RUSSELL | ||||||||
| MiddleName: | E. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3400 DATA DR | ||||||||
| Address2: | |||||||||
| City: | RANCHO CORDOVA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956707956 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3000 Q ST | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958167058 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9167335336 | ||||||||
| FaxNumber: | 9167335385 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2006 | ||||||||
| LastUpdateDate: | 02/10/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VG0400X | G32453 | CA | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 1211321 | 01 | CA | GREAT WEST | OTHER | 4054751 | 01 | CA | AETNA | OTHER | MCMG170800 | 01 | CA | WESTERN HEALTH ADVANTAGE | OTHER | 216368 | 01 | CA | UNITED HEALTHCARE | OTHER | 4364920 | 01 | CA | CIGNA | OTHER | 90018849 | 01 | CA | PACIFICARE | OTHER | 000810354304 | 01 | CA | PHCS | OTHER | 14028 | 01 | CA | INTERPLAN | OTHER | 012413 | 01 | CA | HEALTH NET | OTHER | 4812 | 01 | CA | FIRST HEALTH | OTHER | G62453 | 01 | CA | BLUE CROSS | OTHER | 00G324530 | 05 | CA | MEDICAID |