Basic Information
| Provider Information | |||||||||
| NPI: | 1619971223 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DUMIRE | ||||||||
| FirstName: | RUSSELL | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1086 FRANKLIN ST | ||||||||
| Address2: | |||||||||
| City: | JOHNSTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 159054305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8144108300 | ||||||||
| FaxNumber: | 8144108331 | ||||||||
| Practice Location | |||||||||
| Address1: | 1086 FRANKLIN STREET, | ||||||||
| Address2: | GROUND FLOOR GOOD SAMARITAN BLDG. | ||||||||
| City: | JOHNSTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 15905 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8145349402 | ||||||||
| FaxNumber: | 8145343178 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2005 | ||||||||
| LastUpdateDate: | 10/17/2014 | ||||||||
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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 | 2086S0102X | MD061876L | PA | Y | Allopathic & Osteopathic Physicians | Surgery | Surgical Critical Care |
ID Information
| ID | Type | State | Issuer | Description | 0018822560001 | 05 | PA | MEDICAID |