Provider Demographics
NPI:1245269364
Name:ELWELL, RUSSELL S (MD)
Entity type:Individual
Prefix:
First Name:RUSSELL
Middle Name:S
Last Name:ELWELL
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 1:158 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WESTFIELD
Mailing Address - State:NY
Mailing Address - Zip Code:14787-1155
Mailing Address - Country:US
Mailing Address - Phone:716-326-4686
Mailing Address - Fax:716-326-4628
Practice Address - Street 1:158 E MAIN ST
Practice Address - Street 2:
Practice Address - City:WESTFIELD
Practice Address - State:NY
Practice Address - Zip Code:14787-1155
Practice Address - Country:US
Practice Address - Phone:716-326-4686
Practice Address - Fax:716-326-4628
Is Sole Proprietor?:No
Enumeration Date:2006-07-01
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY115079-1207QA0505X
NY115079208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00607790Medicaid
NY000507267001OtherBLUE CROSS/SHIELD WNY
NY1702196OtherINDEPENDENT HEALTH
NY00010200001OtherUNIVERA
NYD01804Medicare UPIN
NY00607790Medicaid