Basic Information
| Provider Information | |||||||||
| NPI: | 1194838938 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | THOMPSON | ||||||||
| FirstName: | RUSSELL | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1623 HASLETT RD | ||||||||
| Address2: | |||||||||
| City: | HASLETT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48840 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5173392100 | ||||||||
| FaxNumber: | 5173394620 | ||||||||
| Practice Location | |||||||||
| Address1: | 1623 HASLETT RD | ||||||||
| Address2: | |||||||||
| City: | HASLETT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48840 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5176141104 | ||||||||
| FaxNumber: | 5176941692 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2006 | ||||||||
| LastUpdateDate: | 08/12/2010 | ||||||||
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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 | 207R00000X | 4301407218 | MI | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 7388025 | 01 | AETNA | OTHER | 700C312390 | 01 | BCN | OTHER | 6600006 | 01 | PHP | OTHER |