Provider Demographics
NPI:1861564098
Name:RUSSELL, DANIEL W (ANESTHESIOLOGIST)
Entity type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:W
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:ANESTHESIOLOGIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 515
Mailing Address - Street 2:
Mailing Address - City:BARBOURSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:25504-0515
Mailing Address - Country:US
Mailing Address - Phone:304-736-6126
Mailing Address - Fax:304-736-1531
Practice Address - Street 1:2900 1ST AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25702-1241
Practice Address - Country:US
Practice Address - Phone:304-526-1031
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2011-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV17669207L00000X
OH35.062056207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0060658000Medicaid
WV001720692OtherWV BLUE CROSS PROVIDER #
WV550696369-00OtherW.V. WORKERS PROVIDER #
WV001720692OtherWV BLUE CROSS PROVIDER #
F79325Medicare UPIN
OH0760857Medicare PIN