Healthcare Provider Details

I. General information

NPI: 1275891046
Provider Name (Legal Business Name): JOSHUA RUSSELL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/30/2012
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4955 N BAILEY AVE STE 130
AMHERST NY
14226-1206
US

IV. Provider business mailing address

4955 N BAILEY AVE STE 130
AMHERST NY
14226-1206
US

V. Phone/Fax

Practice location:
  • Phone: 716-835-1246
  • Fax: 716-835-0396
Mailing address:
  • Phone: 716-835-1246
  • Fax: 716-835-0396

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number279455
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: