Healthcare Provider Details

I. General information

NPI: 1952485658
Provider Name (Legal Business Name): RUSSELL J PROCTOR MD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 06/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4223 ORANGE BEACH BLVD STE. A
ORANGE BEACH AL
36561-3459
US

IV. Provider business mailing address

PO BOX 7627
MOBILE AL
36670-0627
US

V. Phone/Fax

Practice location:
  • Phone: 251-981-8713
  • Fax:
Mailing address:
  • Phone: 251-974-1550
  • Fax: 251-974-1551

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. RUSSELL J PROCTOR
Title or Position: OWNER
Credential: MD
Phone: 251-974-1550