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NPI Code Detail

MEDICARE: SHANE B RUSSELL-JENKINS MD

MEDICARE: SHANE B RUSSELL-JENKINS MD
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
12084P0800XPsychiatry PhysicianMD2004-0132NM

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1508978750
Entity Type Code : Individual
Provider Name (Legal Business Name) : SHANE B RUSSELL-JENKINS MD
Provider Business Mailing Address
First Line : 2555 E GILA RIDGE RD
Second Line :
City : YUMA
State : AZ
Zip : 85365-2240
Country : US
Telephone Number : 928-317-9972
Fax Number :
Provider Business Practice Location Address
First Line : 2555 E GILA RIDGE RD
Second Line :
City : YUMA
State : AZ
Zip : 85365-2240
Country : US
Telephone Number : 928-317-9972
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/31/2006
Last Update Date : 09/09/2010

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