MEDICARE: REGINA ANN RUSSELL

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	172A00000X	Driver

General Provider Information

NPI Number	:	1194313478
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	REGINA ANN RUSSELL

Provider Business Mailing Address
First Line	:	1818 FAIRMOUNT AVE APT 2
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45214-1293
Country	:	US
Telephone Number	:	513-227-0750
Fax Number	:

Provider Business Practice Location Address
First Line	:	1818 FAIRMOUNT AVE APT 2
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45214-1293
Country	:	US
Telephone Number	:	513-227-0750
Fax Number	:

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

Provider Enumeration Date	:	01/04/2021
Last Update Date	:	01/04/2021

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Directions to “ REGINA ANN RUSSELL ” Practice Location

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