Healthcare Provider Details

I. General information

NPI: 1942645411
Provider Name (Legal Business Name): RUSSELL JOHN KINSEY PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/09/2013
Last Update Date: 05/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

517 N MAIN ST
ANNA IL
62906-1668
US

IV. Provider business mailing address

4971 S PALMER AVE
SPRINGFIELD MO
65804-7482
US

V. Phone/Fax

Practice location:
  • Phone: 618-833-4511
  • Fax: 618-833-4183
Mailing address:
  • Phone: 417-380-1444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085.004652
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: