Provider Demographics
NPI:1871562967
Name:VANDERWILDE, RUSSELL S (MD)
Entity type:Individual
Prefix:
First Name:RUSSELL
Middle Name:S
Last Name:VANDERWILDE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:601 W 5TH AVE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99204-2715
Mailing Address - Country:US
Mailing Address - Phone:509-344-2663
Mailing Address - Fax:509-624-9179
Practice Address - Street 1:601 W 5TH AVE
Practice Address - Street 2:SUITE 400
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99204-2715
Practice Address - Country:US
Practice Address - Phone:509-344-2663
Practice Address - Fax:509-624-9179
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2008-03-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WAMD00030742207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1083047Medicaid
WA200016187OtherRR MEDICARE
IDK6484OtherBLUE CROSS OF IDAHO
WA3780VAOtherASURIS NW HEALTH
WA8919653OtherCRIME VICTIMS
WA3283OtherGROUP HEALTH NW
ID000010002357OtherREGENCE BS OF IDAHO
WA42091OtherDEPT OF LABOR & INDUSTRIE
ID003297000Medicaid
WA379109600OtherOWCP
WA379109600OtherOWCP
WA3780VAOtherASURIS NW HEALTH
WA00304800Medicare ID - Type Unspecified