Healthcare Provider Details

I. General information

NPI: 1891413621
Provider Name (Legal Business Name): MICHAEL RUSSELL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2022
Last Update Date: 08/23/2022
Certification Date: 08/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 E SILVER ST STE 400
SHARON PA
16146-1546
US

IV. Provider business mailing address

4206 HOPKINS RD
YOUNGSTOWN OH
44511-3710
US

V. Phone/Fax

Practice location:
  • Phone: 844-456-5433
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberAPRN.CNP.0031358
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberAPRN.CNP.0031358
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberAPRN.CNP.0031358
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: