Healthcare Provider Details

I. General information

NPI: 1700823879
Provider Name (Legal Business Name): ROBERT C RUSSELL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/31/2006
Last Update Date: 03/21/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 E CARPENTER ST
SPRINGFIELD IL
62702-5185
US

IV. Provider business mailing address

320 E CARPENTER ST
SPRINGFIELD IL
62702-5185
US

V. Phone/Fax

Practice location:
  • Phone: 217-523-0808
  • Fax: 217-753-5324
Mailing address:
  • Phone: 217-523-0808
  • Fax: 217-753-5324

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2082S0105X
TaxonomySurgery of the Hand (Plastic Surgery) Physician
License Number036061657
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number036061657
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number036061657
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: