Healthcare Provider Details

I. General information

NPI: 1467969758
Provider Name (Legal Business Name): TODD RUSSELL CHRISTIAN CAA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/08/2018
Last Update Date: 05/13/2021
Certification Date: 05/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1850 STATE ST
NEW ALBANY IN
47150-4990
US

IV. Provider business mailing address

8607 WESTOVER DR
PROSPECT KY
40059-9483
US

V. Phone/Fax

Practice location:
  • Phone: 812-945-3916
  • Fax:
Mailing address:
  • Phone: 615-975-3899
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License NumberAA643
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License Number75000026A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: