Healthcare Provider Details

I. General information

NPI: 1184691222
Provider Name (Legal Business Name): MARY LOUISE RUSSELL MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2006
Last Update Date: 04/12/2022
Certification Date: 04/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1405 SHADY AVE
PITTSBURGH PA
15217-1350
US

IV. Provider business mailing address

1 MEDICAL CENTER DR P.O.BOX 9196
MORGANTOWN WV
26506-1200
US

V. Phone/Fax

Practice location:
  • Phone: 412-420-2270
  • Fax: 412-420-4450
Mailing address:
  • Phone: 304-293-3909
  • Fax: 304-293-7042

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD044119E
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberMD044119E
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number29378
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: