MEDICARE: KENNETH CARL RUSS MD INC

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	207QA0401X	Addiction Medicine (Family Medicine) Physician

General Provider Information

NPI Number	:	1760334312
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KENNETH CARL RUSS MD INC

Provider Business Mailing Address
First Line	:	5 HOLLAND STE 101
Second Line	:
City	:	IRVINE
State	:	CA
Zip	:	92618-2568
Country	:	US
Telephone Number	:	949-588-2190
Fax Number	:	949-588-2199

Provider Business Practice Location Address
First Line	:	36917 COOK ST STE 103
Second Line	:
City	:	PALM DESERT
State	:	CA
Zip	:	92211-6072
Country	:	US
Telephone Number	:	760-835-0425
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	KENNETH C RUSS
Credential	:	MD
Telephone Number	:	949-588-2190

Provider Enumeration Date	:	02/13/2026
Last Update Date	:	02/13/2026

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