Provider Demographics
NPI:1053365163
Name:RUSSELL, GREGORY D (MD)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:D
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:200 MILL RD
Mailing Address - Street 2:SUITE 180
Mailing Address - City:FAIRHAVEN
Mailing Address - State:MA
Mailing Address - Zip Code:02719-5252
Mailing Address - Country:US
Mailing Address - Phone:508-973-2000
Mailing Address - Fax:508-973-2002
Practice Address - Street 1:49 STATE RD
Practice Address - Street 2:
Practice Address - City:NORTH DARTMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02747-3322
Practice Address - Country:US
Practice Address - Phone:508-973-6650
Practice Address - Fax:508-973-0345
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2020-04-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA150866207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110059962AMedicaid
MAS400135006Medicare PIN
MAJ17954OtherBCBS-MA
MAG64151Medicare UPIN
MA3181448Medicaid
MA66940OtherHARVARD-PILGRIM HEALTHCARE