Healthcare Provider Details

I. General information

NPI: 1376525014
Provider Name (Legal Business Name): ANTHONY HENRYK RUSSELL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2005
Last Update Date: 12/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 BLOSSOM ST COX LL
BOSTON MA
02114-2606
US

IV. Provider business mailing address

PO BOX 9142
CHARLESTOWN MA
02129-9142
US

V. Phone/Fax

Practice location:
  • Phone: 617-726-8650
  • Fax: 617-726-3603
Mailing address:
  • Phone: 617-726-7559
  • Fax: 617-726-3603

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0203X
TaxonomyTherapeutic Radiology Physician
License Number40275
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: