Basic Information
| Provider Information | |||||||||
| NPI: | 1669440772 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | RUSSELL | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 16506 SW 29TH STREET APT K93 | ||||||||
| Address2: | |||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98683 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5094931101 | ||||||||
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| Practice Location | |||||||||
| Address1: | 211 SKYLINE DRIVE | ||||||||
| Address2: | |||||||||
| City: | WHITE SALMON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98672 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5094931101 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2006 | ||||||||
| LastUpdateDate: | 03/09/2012 | ||||||||
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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 | 207P00000X | MD00029546 | WA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | MD14453 | OR | N | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 8117327 | 05 | WA | MEDICAID | 105593 | 05 | OR | MEDICAID | 2081666 | 05 | NV | MEDICAID | XPY196668 | 05 | CA | MEDICAID |