1710204391 NPI number — RUSSELL PET M.D. INC

Table of content: (NPI 1710204391)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710204391 NPI number — RUSSELL PET M.D. INC

Organization/Personal Information

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

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:
1710204391
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/22/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4 HARTWELL ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FALL RIVER
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02721-3019
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
508-675-0089
Provider Business Mailing Address Fax Number:
508-675-2233

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4 HARTWELL ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FALL RIVER
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02721-3019
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
508-675-0089
Provider Business Practice Location Address Fax Number:
508-675-2233
Provider Enumeration Date:
04/22/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
PET
Authorized Official First Name:
L
Authorized Official Middle Name:
RUSSELL
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
508-675-0089

Provider Taxonomy Codes

  • Taxonomy code: 2084P0804X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 3154564 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".