Healthcare Provider Details

I. General information

NPI: 1831288117
Provider Name (Legal Business Name): RUSSELL B ALLISON MDPA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 11/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1605 WEST MAIN ST
RUSSELLVILLE AR
72801
US

IV. Provider business mailing address

PO BOX 1146
RUSSELLVILLE AR
72811
US

V. Phone/Fax

Practice location:
  • Phone: 479-890-9292
  • Fax: 479-890-6962
Mailing address:
  • Phone: 479-890-9292
  • Fax: 479-890-6962

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: RUSSELL B ALLISON
Title or Position: OWNER
Credential: MD
Phone: 479-890-9292