Healthcare Provider Details

I. General information

NPI: 1588662431
Provider Name (Legal Business Name): DR. GARY NELSON RUSSELL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2005
Last Update Date: 02/10/2021
Certification Date: 02/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2950 HIGHWAY 78 E
JASPER AL
35501-8903
US

IV. Provider business mailing address

2950 HIGHWAY 78 E
JASPER AL
35501-8903
US

V. Phone/Fax

Practice location:
  • Phone: 205-221-5374
  • Fax: 205-384-1453
Mailing address:
  • Phone: 205-221-5374
  • Fax: 205-384-1453

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number14702
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number14702
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: