Healthcare Provider Details

I. General information

NPI: 1255743605
Provider Name (Legal Business Name): ERICH RUSSELL D.O
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2014
Last Update Date: 07/07/2020
Certification Date: 07/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33 SEWALL ST
PORTLAND ME
04102-2603
US

IV. Provider business mailing address

324 GANNETT DR STE 200
SOUTH PORTLAND ME
04106-3266
US

V. Phone/Fax

Practice location:
  • Phone: 207-828-2100
  • Fax:
Mailing address:
  • Phone: 207-482-7800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberOS15702
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberOS15702
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateME
# 4
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberDO3056
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: