1023097904 NPI number — DR. RUSSELL C CANTRELL M.D.

Table of content: DR. RUSSELL C CANTRELL M.D. (NPI 1023097904)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023097904 NPI number — DR. RUSSELL C CANTRELL M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CANTRELL
Provider First Name:
RUSSELL
Provider Middle Name:
C
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1023097904
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/06/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 843857
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KANSAS CITY
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
64184-3857
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-966-8887
Provider Business Mailing Address Fax Number:
314-966-3869

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1001 S. KIRKWOOD ROAD
Provider Second Line Business Practice Location Address:
SUITE 120
Provider Business Practice Location Address City Name:
SAINT LOUIS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63122-7250
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-966-8887
Provider Business Practice Location Address Fax Number:
314-966-3869
Provider Enumeration Date:
01/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208100000X , with the licence number:  103654 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0425207002 . This is a "CIGNA" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 227927 . This is a "HEALTHLINK" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 4486251 . This is a "AETNA" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 18346 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 2300015 . This is a "UNITED HEALTH CARE" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 49861 . This is a "GREAT WEST" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".




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