Basic Information
| Provider Information | |||||||||
| NPI: | 1871562967 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VANDERWILDE | ||||||||
| FirstName: | RUSSELL | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 601 W 5TH AVE | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | SPOKANE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 992042715 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5093442663 | ||||||||
| FaxNumber: | 5096249179 | ||||||||
| Practice Location | |||||||||
| Address1: | 601 W 5TH AVE | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | SPOKANE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 992042715 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5093442663 | ||||||||
| FaxNumber: | 5096249179 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2006 | ||||||||
| LastUpdateDate: | 03/11/2008 | ||||||||
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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 | 207X00000X | MD00030742 | WA | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1083047 | 05 | WA | MEDICAID | 200016187 | 01 | WA | RR MEDICARE | OTHER | K6484 | 01 | ID | BLUE CROSS OF IDAHO | OTHER | 3780VA | 01 | WA | ASURIS NW HEALTH | OTHER | 8919653 | 01 | WA | CRIME VICTIMS | OTHER | 3283 | 01 | WA | GROUP HEALTH NW | OTHER | 000010002357 | 01 | ID | REGENCE BS OF IDAHO | OTHER | 42091 | 01 | WA | DEPT OF LABOR & INDUSTRIE | OTHER | 003297000 | 05 | ID | MEDICAID | 379109600 | 01 | WA | OWCP | OTHER |