Healthcare Provider Details

I. General information

NPI: 1649739541
Provider Name (Legal Business Name): JAMES RYAN RUSSELL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2019
Last Update Date: 09/04/2025
Certification Date: 09/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10710 CHARTER DR STE 130
COLUMBIA MD
21044-3258
US

IV. Provider business mailing address

10710 CHARTER DR STE 130
COLUMBIA MD
21044-3258
US

V. Phone/Fax

Practice location:
  • Phone: 410-772-7000
  • Fax: 410-772-7072
Mailing address:
  • Phone: 410-772-7000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberD0102480
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number25MA12135100
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: