1720178445 NPI number — WILLIAM M RUSSELL MD

Table of content: WILLIAM M RUSSELL MD (NPI 1720178445)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720178445 NPI number — WILLIAM M RUSSELL MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RUSSELL
Provider First Name:
WILLIAM
Provider Middle Name:
M
Provider Name Prefix Text:
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:
1720178445
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/13/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5700 LAKE WORTH RD STE 204
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREENACRES
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33463-3213
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
561-966-7707
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5317 ATLANTIC AVE STE 104
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DELRAY BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33484-8175
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
561-496-6000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/13/2006

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: 207R00000X , with the licence number:  D30182 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RG0300X , with the licence number: D0030182 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 39949003 . This is a "BCBS OF MD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 369001600 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0012 . This is a "BCBS OF DC" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0943ER-399490-05 . This is a "CAREFIRST BCBS OF MD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 022252100 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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