Healthcare Provider Details

I. General information

NPI: 1477624823
Provider Name (Legal Business Name): KARL EVERTON RUSSELL-BROWN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/09/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 W 9TH ST
PLAINFIELD NJ
07060-2426
US

IV. Provider business mailing address

203 W 9TH ST
PLAINFIELD NJ
07060-2426
US

V. Phone/Fax

Practice location:
  • Phone: 908-756-5550
  • Fax: 908-756-3072
Mailing address:
  • Phone: 908-756-5550
  • Fax: 908-756-3072

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number25MA03427000
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier0966809
Identifier TypeMEDICAID
Identifier StateNJ
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: