Provider Demographics
NPI:1679547566
Name:RUSSELL, BRENDA R (MD)
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:R
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6626 E. 75TH STREET
Mailing Address - Street 2:SUITE 500
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2890
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8920 SOUTHPOINTE DR
Practice Address - Street 2:SUITE B
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46227-7509
Practice Address - Country:US
Practice Address - Phone:317-497-1900
Practice Address - Fax:317-497-1919
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2015-03-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN01034924A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN080132420OtherRAILROAD MEDICARE #
IN132440EMedicare PIN
IN080132420OtherRAILROAD MEDICARE #
IND95613Medicare UPIN
IN214370FMedicare PIN