Healthcare Provider Details

I. General information

NPI: 1992770515
Provider Name (Legal Business Name): GREGORY A. RUSSELL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2006
Last Update Date: 07/15/2024
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12925 HIGHWAY 601 STE 300
MIDLAND NC
28107-9535
US

IV. Provider business mailing address

PO BOX 19305
CHARLOTTE NC
28219-9305
US

V. Phone/Fax

Practice location:
  • Phone: 704-888-3702
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2010-01130
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: