Healthcare Provider Details

I. General information

NPI: 1104812494
Provider Name (Legal Business Name): LARISA VIKTOROVNA RUSSELL M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2005
Last Update Date: 08/16/2023
Certification Date: 08/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4600 HIGHWAY 280
BIRMINGHAM AL
35242-5028
US

IV. Provider business mailing address

4600 HIGHWAY 280 STE 100
BIRMINGHAM AL
35242-5185
US

V. Phone/Fax

Practice location:
  • Phone: 205-408-1231
  • Fax: 205-408-1229
Mailing address:
  • Phone: 205-408-1231
  • Fax: 205-408-1229

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number057050
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number26797
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: