Healthcare Provider Details

I. General information

NPI: 1841129954
Provider Name (Legal Business Name): EZEKIEL ELIJAH RUSSELL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2026
Last Update Date: 05/15/2026
Certification Date: 05/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29 STANHOPE ST
BOSTON MA
02116-5111
US

IV. Provider business mailing address

29 STANHOPE ST
BOSTON MA
02116-5111
US

V. Phone/Fax

Practice location:
  • Phone: 617-236-1012
  • Fax: 617-236-1012
Mailing address:
  • Phone: 617-236-1012
  • Fax: 617-236-1012

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: