Healthcare Provider Details

I. General information

NPI: 1902112816
Provider Name (Legal Business Name): RONNIE JEROME RUSSELL I M DIV
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2010
Last Update Date: 08/30/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

717 HART LN
NASHVILLE TN
37216-2007
US

IV. Provider business mailing address

230 VENTURE CIR
NASHVILLE TN
37228-1604
US

V. Phone/Fax

Practice location:
  • Phone: 615-227-7688
  • Fax: 615-460-4202
Mailing address:
  • Phone: 615-460-4288
  • Fax: 615-460-4202

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: