Basic Information
| Provider Information | |||||||||
| NPI: | 1215981675 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CLARKE | ||||||||
| FirstName: | RUSSELL | ||||||||
| MiddleName: | P. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4600 WESLEY AVE STE N | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452122274 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5132467800 | ||||||||
| FaxNumber: | 5132467852 | ||||||||
| Practice Location | |||||||||
| Address1: | 6949 GOOD SAMARITAN DR STE 200 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452475206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5132467000 | ||||||||
| FaxNumber: | 5132468855 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2006 | ||||||||
| LastUpdateDate: | 04/25/2012 | ||||||||
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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 | 207X00000X | 35-04-7849 | OH | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 0498377 | 05 | OH | MEDICAID |