Healthcare Provider Details

I. General information

NPI: 1477047728
Provider Name (Legal Business Name): MRS. BEATRICE ANN RUSSELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2018
Last Update Date: 01/23/2025
Certification Date: 01/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33 WHITING HILL RD
BREWER ME
04412-1021
US

IV. Provider business mailing address

43 WHITING HILL RD STE 300
BREWER ME
04412-1006
US

V. Phone/Fax

Practice location:
  • Phone: 207-973-7478
  • Fax: 207-487-3158
Mailing address:
  • Phone: 207-973-7478
  • Fax: 207-973-7807

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberCNP181121
License Number StateME
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCNP181121
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: