Healthcare Provider Details

I. General information

NPI: 1700881679
Provider Name (Legal Business Name): RUSSELL L STEWART D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/16/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

406 MAIN ST
SUTTON WV
26601-1323
US

IV. Provider business mailing address

HC 61 BOX 56C
FRAMETOWN WV
26623-9401
US

V. Phone/Fax

Practice location:
  • Phone: 304-765-2826
  • Fax: 304-765-2841
Mailing address:
  • Phone: 304-364-4136
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number733
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: