Provider Demographics
NPI:1538157730
Name:RUSSELL, KERRY S (MD)
Entity type:Individual
Prefix:
First Name:KERRY
Middle Name:S
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 HOWARD AVE
Mailing Address - Street 2:YALE PHYSICIANS' BUILDING, 2ND FLOOR
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06519-1369
Mailing Address - Country:US
Mailing Address - Phone:203-785-4114
Mailing Address - Fax:203-737-2437
Practice Address - Street 1:800 HOWARD AVE
Practice Address - Street 2:YALE PHYSICIANS' BUILDING, 2ND FLOOR
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06519-1369
Practice Address - Country:US
Practice Address - Phone:203-785-4114
Practice Address - Fax:203-737-2437
Is Sole Proprietor?:No
Enumeration Date:2005-10-11
Last Update Date:2011-03-31
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CT038909207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001389099Medicaid
CT110008104Medicare ID - Type Unspecified
CT001389099Medicaid