Healthcare Provider Details

I. General information

NPI: 1467454322
Provider Name (Legal Business Name): ANTHONY OTIS RUSSELL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2005
Last Update Date: 09/15/2025
Certification Date: 09/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1633 PHYSICIANS DR
TALLAHASSEE FL
32308-4620
US

IV. Provider business mailing address

1633 PHYSICIANS DR
TALLAHASSEE FL
32308-4620
US

V. Phone/Fax

Practice location:
  • Phone: 850-431-3276
  • Fax:
Mailing address:
  • Phone: 850-431-3276
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License NumberME127853
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207LA0401X
TaxonomyAddiction Medicine (Anesthesiology) Physician
License NumberME127853
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License NumberME127853
License Number StateFL
# 4
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberME127853
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: