Basic Information
| Provider Information | |||||||||
| NPI: | 1043219496 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RUSSELL | ||||||||
| FirstName: | TODD | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2109 HUGHES DR | ||||||||
| Address2: | SUITE 450 | ||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436063856 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192912003 | ||||||||
| FaxNumber: | 4194796977 | ||||||||
| Practice Location | |||||||||
| Address1: | 2109 HUGHES DR | ||||||||
| Address2: | SUITE 450 | ||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436063856 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192912003 | ||||||||
| FaxNumber: | 4194796977 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2005 | ||||||||
| LastUpdateDate: | 11/29/2007 | ||||||||
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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 | 2086S0129X | 35074626 | OH | Y | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
ID Information
| ID | Type | State | Issuer | Description | P00366278 | 01 | OH | RRMC | OTHER | 03444 | 01 | OH | PARAMOUNT | OTHER | 5773778 | 01 | OH | AETNA | OTHER | 10221 | 01 | OH | HEALTH PLAN OF MI | OTHER | 000000493404 | 01 | OH | ANTHEM | OTHER | 21-01841 | 01 | OH | UHC | OTHER | 2215678 | 05 | OH | MEDICAID | 4957870 | 05 | MI | MEDICAID |