Healthcare Provider Details

I. General information

NPI: 1780977389
Provider Name (Legal Business Name): TASHA M RUSSELL D.O
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/16/2011
Last Update Date: 06/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

64 KIRK PLZ
INEZ KY
41224
US

IV. Provider business mailing address

PO BOX 697
PRESTONSBURG KY
41653-0697
US

V. Phone/Fax

Practice location:
  • Phone: 606-298-2520
  • Fax: 606-298-2522
Mailing address:
  • Phone: 606-298-2520
  • Fax: 606-298-2522

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number03700
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: