Healthcare Provider Details

I. General information

NPI: 1245220912
Provider Name (Legal Business Name): CHARLES E RUSSELL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/25/2005
Last Update Date: 07/23/2024
Certification Date: 07/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 S MAIN ST
WAYNESVILLE OH
45068-9553
US

IV. Provider business mailing address

3195 DAYTON XENIA RD # 900-162
BEAVERCREEK OH
45434-6390
US

V. Phone/Fax

Practice location:
  • Phone: 513-897-7162
  • Fax:
Mailing address:
  • Phone: 937-718-7677
  • Fax: 937-429-7441

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083A0300X
TaxonomyAddiction Medicine (Preventive Medicine) Physician
License Number35050063
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: