Healthcare Provider Details

I. General information

NPI: 1316428931
Provider Name (Legal Business Name): KENNETH RUSS MD, PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/22/2018
Last Update Date: 08/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

490 S FARRELL DR STE C106
PALM SPRINGS CA
92262-7962
US

IV. Provider business mailing address

5 HOLLAND STE 101
IRVINE CA
92618-2568
US

V. Phone/Fax

Practice location:
  • Phone: 760-416-6773
  • Fax:
Mailing address:
  • Phone: 949-588-2190
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: KENNETH RUSS
Title or Position: PRESIDENT
Credential: M.D.
Phone: 949-588-2190