=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063685667
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BERNADITH RUSSELL, MD, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/04/2008
-----------------------------------------------------
Last Update Date | 04/29/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 430 W BROADWAY 2ND FLOOR
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10012-3784
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-941-0011
-----------------------------------------------------
Fax | 212-941-5977
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 430 W BROADWAY 2ND FLOOR
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10012-3784
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-941-0011
-----------------------------------------------------
Fax | 212-941-5977
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | BERNADITH RUSSELL
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 646-246-2936
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 223267
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------