Healthcare Provider Details

I. General information

NPI: 1326095837
Provider Name (Legal Business Name): RUSSELL S CHERRY PH. D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2006
Last Update Date: 05/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4241 B ST SUITE 202
ANCHORAGE AK
99503-5920
US

IV. Provider business mailing address

4241 B ST SUITE 202
ANCHORAGE AK
99503-5920
US

V. Phone/Fax

Practice location:
  • Phone: 907-277-0100
  • Fax: 907-222-0566
Mailing address:
  • Phone: 907-277-0100
  • Fax: 907-222-0566

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number524
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: