Healthcare Provider Details

I. General information

NPI: 1245272178
Provider Name (Legal Business Name): ROBERT J RUSSELL EDD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 HAWLEY ST
BINGHAMTON NY
13901-3102
US

IV. Provider business mailing address

1255 FOWLER PL
BINGHAMTON NY
13903-6036
US

V. Phone/Fax

Practice location:
  • Phone: 607-778-1118
  • Fax: 607-778-1164
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number009923
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number009923
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: