Healthcare Provider Details

I. General information

NPI: 1164081568
Provider Name (Legal Business Name): ROBERT AUSTIN RUSSELL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2019
Last Update Date: 06/29/2023
Certification Date: 06/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2550 E GUADALUPE RD STE 109
GILBERT AZ
85234-5114
US

IV. Provider business mailing address

2550 E GUADALUPE RD STE 109
GILBERT AZ
85234-5114
US

V. Phone/Fax

Practice location:
  • Phone: 480-785-2100
  • Fax:
Mailing address:
  • Phone: 480-785-2100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number4351044614
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: