Healthcare Provider Details

I. General information

NPI: 1609879253
Provider Name (Legal Business Name): DALLAS M RUSSELL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2005
Last Update Date: 03/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

790 MONTCLAIR RD STE 210
BIRMINGHAM AL
35213-1966
US

IV. Provider business mailing address

790 MONTCLAIR RD STE 210
BIRMINGHAM AL
35213-1966
US

V. Phone/Fax

Practice location:
  • Phone: 205-595-3600
  • Fax: 205-595-3663
Mailing address:
  • Phone: 205-595-3600
  • Fax: 205-595-3663

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number12098
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number12098
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: