MEDICARE: DR. LARISA VIKTOROVNA RUSSELL M.D.

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	207Q00000X	Family Medicine Physician	057050	GA
2	207Q00000X	Family Medicine Physician	26797	AL

General Provider Information

NPI Number	:	1104812494
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LARISA VIKTOROVNA RUSSELL M.D.

Provider Business Mailing Address
First Line	:	4600 HIGHWAY 280 STE 100
Second Line	:
City	:	BIRMINGHAM
State	:	AL
Zip	:	35242-5185
Country	:	US
Telephone Number	:	205-408-1231
Fax Number	:	205-408-1229

Provider Business Practice Location Address
First Line	:	4600 HIGHWAY 280
Second Line	:
City	:	BIRMINGHAM
State	:	AL
Zip	:	35242-5028
Country	:	US
Telephone Number	:	205-408-1231
Fax Number	:	205-408-1229

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

Provider Enumeration Date	:	09/22/2005
Last Update Date	:	08/16/2023

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