Healthcare Provider Details

I. General information

NPI: 1386859148
Provider Name (Legal Business Name): SHERILYN JOSEPHINE RUSSELL MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2007
Last Update Date: 12/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22201 MOROSS RD SUITE 252
GROSSE POINTE MI
48236-2169
US

IV. Provider business mailing address

22201 MOROSS RD SUITE 252
GROSSE POINTE MI
48236-2169
US

V. Phone/Fax

Practice location:
  • Phone: 313-343-4411
  • Fax: 313-343-4412
Mailing address:
  • Phone: 313-343-4411
  • Fax: 313-343-4412

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number4301084057
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4301084057
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4301084057
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: