Healthcare Provider Details

I. General information

NPI: 1174727267
Provider Name (Legal Business Name): HOLLY RUSSELL M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2007
Last Update Date: 02/23/2022
Certification Date: 02/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18210 LA GRANGE RD SUITE 205
TINLEY PARK IL
60487-7722
US

IV. Provider business mailing address

18210 LA GRANGE RD STE 205
TINLEY PARK IL
60487-7725
US

V. Phone/Fax

Practice location:
  • Phone: 708-478-7800
  • Fax: 708-478-7870
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number2005017735
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036120579
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: