Healthcare Provider Details

I. General information

NPI: 1801286059
Provider Name (Legal Business Name): ROBERT CODY RUSSELL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/27/2015
Last Update Date: 01/27/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1118 ROSS CLARK CIRCLE, SUITE 100
DOTHAN AL
36301
US

IV. Provider business mailing address

1118 ROSS CLARK CIRCLE, SUITE 100
DOTHAN AL
36301
US

V. Phone/Fax

Practice location:
  • Phone: 334-794-1148
  • Fax:
Mailing address:
  • Phone: 334-794-1148
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number1-130087
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: