1447280300 NPI number — DR. BRUCE WAYNE RUSSELL MD

Table of content: DR. BRUCE WAYNE RUSSELL MD (NPI 1447280300)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447280300 NPI number — DR. BRUCE WAYNE RUSSELL MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RUSSELL
Provider First Name:
BRUCE
Provider Middle Name:
WAYNE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1447280300
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/07/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 159
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SUMITON
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35148-0159
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
205-648-6637
Provider Business Mailing Address Fax Number:
205-648-5186

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
385 BRYAN RD STE 100
Provider Second Line Business Practice Location Address:
COMMUNITY PROFESSIONAL BUILDING
Provider Business Practice Location Address City Name:
SUMITON
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35148-3422
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
205-648-6637
Provider Business Practice Location Address Fax Number:
205-648-5186
Provider Enumeration Date:
07/04/2006

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: 208D00000X , with the licence number:  4253 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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