Healthcare Provider Details

I. General information

NPI: 1497955868
Provider Name (Legal Business Name): RUSSELL ENSIGN DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2007
Last Update Date: 10/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 SIXTH ST SW MEDICAL EDUCATION
CANTON OH
44710-1702
US

IV. Provider business mailing address

2600 SIXTH ST SW MEDICAL EDUCATION
CANTON OH
44710-1702
US

V. Phone/Fax

Practice location:
  • Phone: 330-363-4899
  • Fax: 330-580-5513
Mailing address:
  • Phone: 330-363-4899
  • Fax: 330-580-5513

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number58-002355
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number34.010108
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: