Healthcare Provider Details

I. General information

NPI: 1265420673
Provider Name (Legal Business Name): ROBERT IRVING RUSSELL DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2005
Last Update Date: 02/28/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1717 11TH AVE SOUTH SUITE 402
BIRMINGHAM AL
35205-4700
US

IV. Provider business mailing address

1717 11TH AVE S
BIRMINGHAM AL
35205-4700
US

V. Phone/Fax

Practice location:
  • Phone: 205-933-9595
  • Fax: 205-933-5250
Mailing address:
  • Phone: 205-933-9595
  • Fax: 205-933-5250

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number94
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number94
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: