1366428476 NPI number — MS. MICHELLE M RUSSELL DO

Table of content: MS. MICHELLE M RUSSELL DO (NPI 1366428476)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366428476 NPI number — MS. MICHELLE M RUSSELL DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RUSSELL
Provider First Name:
MICHELLE
Provider Middle Name:
M
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
F

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:
1366428476
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/24/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7700 WASHINGTON VILLAGE DR STE 210
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CENTERVILLE
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45459-4094
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
937-562-2291
Provider Business Mailing Address Fax Number:
937-562-2293

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7700 WASHINGTON VILLAGE DR STE 210
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CENTERVILLE
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45459-4094
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
937-562-2291
Provider Business Practice Location Address Fax Number:
937-562-2293
Provider Enumeration Date:
12/20/2005

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: 207Q00000X , with the licence number:  34005033 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 590581 . This is a "AETNA" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 34005033R . This is a "MEDICAL LICENSE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 421534506073 . This is a "CARESOURCE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: D0503304 . This is a "HUMANA/CHOICECARE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: OC06218 . This is a "NATIONWIDE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 0887394 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0120237 . This is a "UNITED HEALTH CARE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 000000227882 . This is a "ANTHEM" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 080191704 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 000000227882 . This is a "UNICARE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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