Healthcare Provider Details

I. General information

NPI: 1447206933
Provider Name (Legal Business Name): RAYMOND S RUSSELL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2006
Last Update Date: 11/24/2020
Certification Date: 11/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4000 MIAMISBURG CENTERVILLE RD SUITE 405
MIAMISBURG OH
45342-7615
US

IV. Provider business mailing address

4000 MIAMISBURG CENTERVILLE RD STE 207
MIAMISBURG OH
45342-3674
US

V. Phone/Fax

Practice location:
  • Phone: 937-560-2011
  • Fax: 937-560-2012
Mailing address:
  • Phone: 937-560-2011
  • Fax: 937-560-2012

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number35073039
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: