Healthcare Provider Details

I. General information

NPI: 1821157983
Provider Name (Legal Business Name): MICHAEL J RUSSELL PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2025 MORSE AVE
SACRAMENTO CA
95825
US

IV. Provider business mailing address

216 F ST #76
DAVIS CA
95616
US

V. Phone/Fax

Practice location:
  • Phone: 916-973-6847
  • Fax: 916-973-5611
Mailing address:
  • Phone: 530-668-8988
  • Fax: 530-668-1229

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZE0600X
TaxonomyElectroneurodiagnostic Specialist/Technologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: