Healthcare Provider Details

I. General information

NPI: 1891772513
Provider Name (Legal Business Name): LARRY JOE RUSSELL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/22/2005
Last Update Date: 07/14/2026
Certification Date: 07/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

442 BATTLE CREEK RD
HORSE SHOE NC
28742-4722
US

IV. Provider business mailing address

442 BATTLE CREEK RD
HORSE SHOE NC
28742-4722
US

V. Phone/Fax

Practice location:
  • Phone: 828-753-9194
  • Fax: 828-693-4871
Mailing address:
  • Phone: 828-753-9194
  • Fax: 828-693-4871

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number9901016
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: