Basic Information
Provider Information
NPI: 1003801283
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: JOHNSON
FirstName: RUSSELL
MiddleName: F
NamePrefix:  
NameSuffix:  
Credential: MD
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 710 N NILES AVE
Address2:  
City: SOUTH BEND
State: IN
PostalCode: 466171924
CountryCode: US
TelephoneNumber: 5746471610
FaxNumber:  
Practice Location
Address1: 615 N MICHIGAN ST
Address2: 1ST FLOOR
City: SOUTH BEND
State: IN
PostalCode: 466011033
CountryCode: US
TelephoneNumber: 5746477461
FaxNumber:  
Other Information
ProviderEnumerationDate: 09/14/2005
LastUpdateDate: 08/15/2016
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
2085R0001X01039533INY Allopathic & Osteopathic PhysiciansRadiologyRadiation Oncology

ID Information
IDTypeStateIssuerDescription
00000098659301INANTHEMOTHER
20000171005IN MEDICAID
P0167614601INRR MEDICAREOTHER
00000098659101INANTHEMOTHER


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