Basic Information
| Provider Information | |||||||||
| NPI: | 1609039973 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RUSSELL | ||||||||
| FirstName: | EVAN | ||||||||
| MiddleName: | T | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 775383 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606775383 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123765315 | ||||||||
| FaxNumber: | 8123753477 | ||||||||
| Practice Location | |||||||||
| Address1: | 2325 18TH ST | ||||||||
| Address2: | SUITE 130 | ||||||||
| City: | COLUMBUS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 472015388 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123792020 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2008 | ||||||||
| LastUpdateDate: | 10/31/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/31/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0011X | 01068153A | IN | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology | 208M00000X | 01068153A | IN | N | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 201012920 | 05 | IN | MEDICAID |