Healthcare Provider Details

I. General information

NPI: 1245258235
Provider Name (Legal Business Name): KENNETH CARL RUSS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7885 ANNANDALE AVE
DESERT HOT SPRINGS CA
92240-1419
US

IV. Provider business mailing address

36917 COOK ST STE 103
PALM DESERT CA
92211-6072
US

V. Phone/Fax

Practice location:
  • Phone: 760-329-2924
  • Fax:
Mailing address:
  • Phone: 760-835-0425
  • Fax: 760-416-6843

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License NumberA48224
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: