Healthcare Provider Details

I. General information

NPI: 1023097904
Provider Name (Legal Business Name): RUSSELL C CANTRELL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2006
Last Update Date: 02/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 S. KIRKWOOD ROAD SUITE 120
SAINT LOUIS MO
63122-7250
US

IV. Provider business mailing address

PO BOX 843857
KANSAS CITY MO
64184-3857
US

V. Phone/Fax

Practice location:
  • Phone: 314-966-8887
  • Fax: 314-966-3869
Mailing address:
  • Phone: 314-966-8887
  • Fax: 314-966-3869

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number103654
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: