Provider Demographics
NPI:1609039973
Name:RUSSELL, EVAN T (MD)
Entity type:Individual
Prefix:
First Name:EVAN
Middle Name:T
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 775383
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-5383
Mailing Address - Country:US
Mailing Address - Phone:812-376-5315
Mailing Address - Fax:
Practice Address - Street 1:2325 18TH ST
Practice Address - Street 2:SUITE 130
Practice Address - City:COLUMBUS
Practice Address - State:IN
Practice Address - Zip Code:47201-5388
Practice Address - Country:US
Practice Address - Phone:812-379-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-08
Last Update Date:2024-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01068153A208M00000X, 207RI0011X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201012920Medicaid
IN201012920Medicaid
INM400047148Medicare PIN