Basic Information
| Provider Information | |||||||||
| NPI: | 1801873344 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SMIDT | ||||||||
| FirstName: | RUSSELL | ||||||||
| MiddleName: | G | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6465 WAYZATA BLVD | ||||||||
| Address2: | STE 315 | ||||||||
| City: | ST LOUIS PARK | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554261728 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9529937169 | ||||||||
| FaxNumber: | 9529930300 | ||||||||
| Practice Location | |||||||||
| Address1: | 1885 PLAZA DR | ||||||||
| Address2: | PARK NICOLLET CLINIC - EAGAN | ||||||||
| City: | EAGAN | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551222612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9529934001 | ||||||||
| FaxNumber: | 9529934075 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/27/2005 | ||||||||
| LastUpdateDate: | 10/06/2011 | ||||||||
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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 | 208000000X | 38657 | MN | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.