Healthcare Provider Details

I. General information

NPI: 1265420210
Provider Name (Legal Business Name): LISA M RUSSELL M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/12/2005
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 S CALIFORNIA AVE
CHICAGO IL
60608-1732
US

IV. Provider business mailing address

3537 PAYSPHERE CIR
CHICAGO IL
60674-0035
US

V. Phone/Fax

Practice location:
  • Phone: 773-257-6468
  • Fax:
Mailing address:
  • Phone: 708-786-2900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: