Healthcare Provider Details

I. General information

NPI: 1144213240
Provider Name (Legal Business Name): RICHARD B RUSSELL D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2005
Last Update Date: 11/01/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 N TULPEHOCKEN ST
PINE GROVE PA
17963-1217
US

IV. Provider business mailing address

121 N TULPEHOCKEN ST
PINE GROVE PA
17963-1217
US

V. Phone/Fax

Practice location:
  • Phone: 570-345-2345
  • Fax: 570-345-2350
Mailing address:
  • Phone: 570-345-2345
  • Fax: 570-345-2350

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS004201L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: