Healthcare Provider Details

I. General information

NPI: 1265580096
Provider Name (Legal Business Name): CAROL MAE RUSSELL DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/08/2007
Last Update Date: 02/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 BAY AVE
MONTCLAIR NJ
07042-4837
US

IV. Provider business mailing address

452 OLD HOOK RD 2ND FLOOR
EMERSON NJ
07630-1381
US

V. Phone/Fax

Practice location:
  • Phone: 973-429-6000
  • Fax: 973-429-6209
Mailing address:
  • Phone: 201-666-3900
  • Fax: 201-261-0505

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number238185
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: