Healthcare Provider Details

I. General information

NPI: 1902334014
Provider Name (Legal Business Name): ROSS RUSSELL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2017
Last Update Date: 05/18/2021
Certification Date: 05/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 REID PKWY
RICHMOND IN
47374-1157
US

IV. Provider business mailing address

1100 REID PARKWAY MEDICAL STAFF SERVICES
RICHMOND IN
47374
US

V. Phone/Fax

Practice location:
  • Phone: 765-983-3144
  • Fax: 765-983-3038
Mailing address:
  • Phone: 765-935-8802
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberBP10061474
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number01084384A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: