Basic Information
| Provider Information | |||||||||
| NPI: | 1811007966 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILKE | ||||||||
| FirstName: | RUSSELL | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5074 | ||||||||
| Address2: | |||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571175074 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1205 S GRANGE AVE | ||||||||
| Address2: | STE 510 | ||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571050407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053287500 | ||||||||
| FaxNumber: | 6053287599 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2006 | ||||||||
| LastUpdateDate: | 02/26/2016 | ||||||||
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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 | 207R00000X | 38145 | WI | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 45694 | TN | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 42291 | MN | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 12805 | ND | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 9764 | SD | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1519301 | 05 | TN | MEDICAID | 32289100 | 05 | WI | MEDICAID | 18144 | 05 | ND | MEDICAID |