Healthcare Provider Details

I. General information

NPI: 1194838938
Provider Name (Legal Business Name): RUSSELL C THOMPSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2006
Last Update Date: 08/12/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1623 HASLETT RD
HASLETT MI
48840
US

IV. Provider business mailing address

1623 HASLETT RD
HASLETT MI
48840
US

V. Phone/Fax

Practice location:
  • Phone: 517-614-1104
  • Fax: 517-694-1692
Mailing address:
  • Phone: 517-339-2100
  • Fax: 517-339-4620

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4301407218
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: