MEDICARE: MR. ROBERT J RUSSELL PCNS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	364SP0808X	Psychiatric/Mental Health Clinical Nurse Specialist	182877	MA
2	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	182877	MA

General Provider Information

NPI Number	:	1003890518
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ROBERT J RUSSELL PCNS

Provider Business Mailing Address
First Line	:	280 CHESTNUT STREET 2ND FLOOR
Second Line	:
City	:	SPRINGFIELD
State	:	MA
Zip	:	01199
Country	:	US
Telephone Number	:	413-794-5700
Fax Number	:

Provider Business Practice Location Address
First Line	:	759 CHESTNUT ST
Second Line	:
City	:	SPRINGFIELD
State	:	MA
Zip	:	01199-1001
Country	:	US
Telephone Number	:	413-794-3376
Fax Number	:	413-794-9803

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/30/2005
Last Update Date	:	06/24/2015

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