MEDICARE: RUSSELL DILLARD

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	104100000X	Social Worker	LG50078875	DC

General Provider Information

NPI Number	:	1790324788
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RUSSELL DILLARD

Provider Business Mailing Address
First Line	:	5053 12TH ST NE
Second Line	:
City	:	WASHINGTON
State	:	DC
Zip	:	20017-2851
Country	:	US
Telephone Number	:	202-247-7583
Fax Number	:

Provider Business Practice Location Address
First Line	:	1554 COLUMBIA PIKE
Second Line	:
City	:	ARLINGTON
State	:	VA
Zip	:	22204-4667
Country	:	US
Telephone Number	:	703-228-0045
Fax Number	:

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

Provider Enumeration Date	:	12/23/2019
Last Update Date	:	12/23/2019

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Directions to “ RUSSELL DILLARD ” Practice Location

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