Healthcare Provider Details

I. General information

NPI: 1073755971
Provider Name (Legal Business Name): JAMES MILLER RUSSELL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/24/2009
Last Update Date: 03/23/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

141 SW WRIGHT AVE
PORTLAND OR
97205-5865
US

IV. Provider business mailing address

141 SW WRIGHT AVE
PORTLAND OR
97205-5865
US

V. Phone/Fax

Practice location:
  • Phone: 503-384-2696
  • Fax:
Mailing address:
  • Phone: 503-384-2696
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084B0040X
TaxonomyBehavioral Neurology & Neuropsychiatry Physician
License NumberMD179941
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: