1992021315 NPI number — MR. BRIAN D RUSSELL FNP-BC

Table of content: MR. BRIAN D RUSSELL FNP-BC (NPI 1992021315)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992021315 NPI number — MR. BRIAN D RUSSELL FNP-BC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RUSSELL
Provider First Name:
BRIAN
Provider Middle Name:
D
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
FNP-BC
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:
1992021315
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/06/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
319 LINCOLN ST APT 505
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HINGHAM
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02043-1777
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
865-806-9161
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
143 LONGWATER DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORWELL
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02061-1683
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
781-878-5200
Provider Business Practice Location Address Fax Number:
781-878-6750
Provider Enumeration Date:
04/09/2010

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: 363LF0000X , with the licence number:  14835 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: RN2330343 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1523401 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: P01504956 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 1992021315 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".