Healthcare Provider Details

I. General information

NPI: 1548323090
Provider Name (Legal Business Name): DENNIS MICHEAL RUSSELL ATC, NRP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/18/2006
Last Update Date: 06/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

192 RUSSELL ST
LEWISTON ME
04240-5435
US

IV. Provider business mailing address

192 RUSSELL ST
LEWISTON ME
04240-5435
US

V. Phone/Fax

Practice location:
  • Phone: 207-777-6006
  • Fax:
Mailing address:
  • Phone: 207-777-6006
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code146L00000X
TaxonomyParamedic
License Number20114
License Number StateME
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT139
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: