Healthcare Provider Details

I. General information

NPI: 1881012441
Provider Name (Legal Business Name): RUSSELL EMMETT DAVENPORT III M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2014
Last Update Date: 06/27/2025
Certification Date: 06/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2711 RANDOLPH RD STE 207
CHARLOTTE NC
28207-2027
US

IV. Provider business mailing address

2711 RANDOLPH RD STE 207
CHARLOTTE NC
28207-2027
US

V. Phone/Fax

Practice location:
  • Phone: 704-862-4700
  • Fax: 704-862-4749
Mailing address:
  • Phone: 704-862-4700
  • Fax: 704-862-4789

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number2019-01531
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number82514
License Number StateSC
# 3
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number2019-01531
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: