Basic Information
| Provider Information | |||||||||
| NPI: | 1609968452 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RAPHAELY | ||||||||
| FirstName: | RUSSELL | ||||||||
| MiddleName: | C. | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | NEMOURS CHILDRENS CLINIC | ||||||||
| Address2: | P.O. BOX 404112 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303840001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043903610 | ||||||||
| FaxNumber: | 9042885890 | ||||||||
| Practice Location | |||||||||
| Address1: | A.I. DUPONT HOSPITAL FOR CHILDREN | ||||||||
| Address2: | 1600 ROCKLAND ROAD | ||||||||
| City: | WILMINGTON | ||||||||
| State: | DE | ||||||||
| PostalCode: | 198033607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3026514000 | ||||||||
| FaxNumber: | 3026514945 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2006 | ||||||||
| LastUpdateDate: | 09/11/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | C10005241 | DE | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207LP3000X | C10005241 | DE | Y | Allopathic & Osteopathic Physicians | Anesthesiology | Pediatric Anesthesiology | 2080P0203X | C10005241 | DE | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Critical Care Medicine | 207L00000X | MA06427200 | NJ | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | MD007844E | PA | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207LP3000X | MA06427200 | NJ | N | Allopathic & Osteopathic Physicians | Anesthesiology | Pediatric Anesthesiology | 207LP3000X | MD007844E | PA | N | Allopathic & Osteopathic Physicians | Anesthesiology | Pediatric Anesthesiology | 2080P0203X | MA06427200 | NJ | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Critical Care Medicine | 2080P0203X | MD007844E | PA | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Critical Care Medicine |
ID Information
| ID | Type | State | Issuer | Description | 4399102 | 05 | MD | MEDICAID | 64572621 | 05 | KY | MEDICAID | 1569895 | 05 | LA | MEDICAID | 956134 | 05 | NY | MEDICAID | P8B187880 | 05 | TX | MEDICAID | 806298000 | 05 | ID | MEDICAID | 000684273 | 05 | PA | MEDICAID | 0224006 | 05 | NJ | MEDICAID |