Healthcare Provider Details

I. General information

NPI: 1629065685
Provider Name (Legal Business Name): RUSSELL B BRANUM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2005
Last Update Date: 04/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 S WALDRON RD STE 202
FORT SMITH AR
72903-2574
US

IV. Provider business mailing address

PO BOX 11436
FORT SMITH AR
72917-1436
US

V. Phone/Fax

Practice location:
  • Phone: 479-755-6900
  • Fax: 479-755-6903
Mailing address:
  • Phone: 479-755-6900
  • Fax: 479-755-6903

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License NumberE3265
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: