Healthcare Provider Details

I. General information

NPI: 1184627945
Provider Name (Legal Business Name): ALLEN J RUSSELL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/24/2005
Last Update Date: 11/09/2023
Certification Date: 11/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

32401 8 MILE RD
LIVONIA MI
48152-1301
US

IV. Provider business mailing address

6601 COLLEGE BLVD STE 120
OVERLAND PARK KS
66211-1504
US

V. Phone/Fax

Practice location:
  • Phone: 913-359-6001
  • Fax: 913-359-5552
Mailing address:
  • Phone: 913-359-6001
  • Fax: 217-897-6999

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number4301042036
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number4301042036
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: