Provider Demographics
NPI:1871606210
Name:SHIPMAN, RUSSELL (DO)
Entity type:Individual
Prefix:
First Name:RUSSELL
Middle Name:
Last Name:SHIPMAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10140 CENTURION PKWY N
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-0532
Mailing Address - Country:US
Mailing Address - Phone:904-697-4100
Mailing Address - Fax:904-697-5102
Practice Address - Street 1:13535 NEMOURS PKWY
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32827-7402
Practice Address - Country:US
Practice Address - Phone:407-567-4000
Practice Address - Fax:407-567-5924
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2024-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34.016517208000000X
IN02007801A208000000X, 208M00000X
FLOS131062080P0204X, 208M00000X
NH25439208000000X
VA0102208378208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL014 526 800Medicaid
NH30233307Medicaid
NH0404011YPME02OtherBCBS OF NH
MEM121911COtherCIGNA
ME408230099Medicaid
MEG34607OtherHARVARD PILGRIM
ME2824368OtherAETNA
ME047343OtherBCBS
ME5924615OtherAETNA