Healthcare Provider Details

I. General information

NPI: 1942377189
Provider Name (Legal Business Name): RUSSELL M GILBERTSON MD A PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2006
Last Update Date: 10/29/2021
Certification Date: 10/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1246 W 155TH ST
GARDENA CA
90247-4011
US

IV. Provider business mailing address

PO BOX 3129
TORRANCE CA
90510-3129
US

V. Phone/Fax

Practice location:
  • Phone: 562-407-2080
  • Fax:
Mailing address:
  • Phone: 310-792-3914
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberG476910
License Number StateCA

VIII. Authorized Official

Name: RUSSELL GILBERTSON
Title or Position: PRESIDENT
Credential: MD
Phone: 562-407-2080