Healthcare Provider Details

I. General information

NPI: 1962527655
Provider Name (Legal Business Name): DEBORAH L RUSSELL MD PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/20/2007
Last Update Date: 08/24/2021
Certification Date: 08/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4177 FASHION SQUARE BLVD. SUITE # 1
SAGINAW MI
48603-5216
US

IV. Provider business mailing address

4177 FASHION SQUARE BLVD. SUITE # 1
SAGINAW MI
48603-5216
US

V. Phone/Fax

Practice location:
  • Phone: 989-791-9100
  • Fax: 989-791-6746
Mailing address:
  • Phone: 989-791-9100
  • Fax: 989-791-6746

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number4301053500
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704246844
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. DEBORAH LEE RUSSELL
Title or Position: OWNER
Credential: MD
Phone: 989-791-9100