Provider Demographics
NPI:1578552444
Name:RUSSELL, LAINE C (DO)
Entity type:Individual
Prefix:
First Name:LAINE
Middle Name:C
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:407 S MEDICAL ARTS CT
Mailing Address - Street 2:SUITE F
Mailing Address - City:GILLETTE
Mailing Address - State:WY
Mailing Address - Zip Code:82716-3372
Mailing Address - Country:US
Mailing Address - Phone:307-682-1441
Mailing Address - Fax:307-686-3619
Practice Address - Street 1:407 S MEDICAL ARTS CT
Practice Address - Street 2:SUITE F
Practice Address - City:GILLETTE
Practice Address - State:WY
Practice Address - Zip Code:82716-3372
Practice Address - Country:US
Practice Address - Phone:307-682-1441
Practice Address - Fax:307-686-3619
Is Sole Proprietor?:No
Enumeration Date:2005-10-13
Last Update Date:2008-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY6623A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0078812Medicaid
WY312895OtherBLUE CROSS BLUE SHIELD
WYP00140483OtherRAILROAD MEDICARE
WY10121Medicare ID - Type Unspecified
WY312895OtherBLUE CROSS BLUE SHIELD