Provider Demographics
NPI:1528062148
Name:HORN, RUSSELL R (DO)
Entity type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:R
Last Name:HORN
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 1:122 N PARK AVE
Mailing Address - Street 2:
Mailing Address - City:VALLEY CENTER
Mailing Address - State:KS
Mailing Address - Zip Code:67147-2553
Mailing Address - Country:US
Mailing Address - Phone:316-755-1511
Mailing Address - Fax:316-755-0991
Practice Address - Street 1:122 N PARK AVE
Practice Address - Street 2:
Practice Address - City:VALLEY CENTER
Practice Address - State:KS
Practice Address - Zip Code:67147-2553
Practice Address - Country:US
Practice Address - Phone:316-755-1511
Practice Address - Fax:316-755-0991
Is Sole Proprietor?:No
Enumeration Date:2005-06-10
Last Update Date:2008-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0520832207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100229730EMedicaid
KS0000106575OtherBLUE CROSS BLUE SHIELD
KS100416440AMedicaid
KSP00057331OtherRAIL ROAD MEDICARE
KS100229730CMedicaid
KS103177OtherBLUE CROSS INDIVIDUAL
KS111178OtherBLUE CROSS BLUE SHIELD
KS607740OtherFIRSTGUARD
KS111178OtherMEDICARE GROUP
KS103177OtherBLUE CROSS INDIVIDUAL
KS103177Medicare ID - Type UnspecifiedINDIVIDUAL
KS100229730CMedicaid