Healthcare Provider Details

I. General information

NPI: 1750518049
Provider Name (Legal Business Name): KATHRYN WHITE RUSSELL MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2009
Last Update Date: 11/17/2021
Certification Date: 11/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3401 CIVIC CENTER BLVD DIVISION OF PEDIATRIC SURGERY
PHILADELPHIA PA
19104-4319
US

IV. Provider business mailing address

3401 CIVIC CENTER BLVD DIVISION OF PEDIATRIC SURGERY
PHILADELPHIA PA
19104-4319
US

V. Phone/Fax

Practice location:
  • Phone: 215-590-1190
  • Fax:
Mailing address:
  • Phone: 215-590-1190
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0120X
TaxonomyPediatric Surgery Physician
License NumberMT207856
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: