Healthcare Provider Details

I. General information

NPI: 1629018767
Provider Name (Legal Business Name): MARK D RUSS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2006
Last Update Date: 03/24/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

767 WOOD AVE E
BIG STONE GAP VA
24219-3023
US

IV. Provider business mailing address

PO BOX 857
BIG STONE GAP VA
24219-3366
US

V. Phone/Fax

Practice location:
  • Phone: 276-523-1006
  • Fax: 276-523-5293
Mailing address:
  • Phone: 276-523-1006
  • Fax: 276-523-5293

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number0101051554
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: