Healthcare Provider Details

I. General information

NPI: 1760334312
Provider Name (Legal Business Name): KENNETH CARL RUSS MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2026
Last Update Date: 02/13/2026
Certification Date: 02/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

5 HOLLAND STE 101
IRVINE CA
92618-2568
US

V. Phone/Fax

Practice location:
  • Phone: 760-835-0425
  • Fax:
Mailing address:
  • Phone: 949-588-2190
  • Fax: 949-588-2199

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: KENNETH C RUSS
Title or Position: OWNER
Credential: MD
Phone: 949-588-2190