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General NPI Number Information
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NPI Number | 1063765659
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Entity Type | Organization
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Legal Business Name | ADAM J RUSS OD LLC
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Dates
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Enumeration Date | 10/19/2012
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Last Update Date | 08/11/2016
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Provider Practice Location Address
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Address Line | 562 S GREEN RIVER RD
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City | EVANSVILLE
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State | IN
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Zip | 47715-7308
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Country | US
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Telephone | 812-479-5208
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Fax |
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Provider Business Mailing Address
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Address Line | 562 S GREEN RIVER RD
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City | EVANSVILLE
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State | IN
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Zip | 47715-7308
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Country | US
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Telephone | 812-479-5208
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Fax |
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Authorized Official
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Title or Position | OPTOMETRIST
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Name | DR. ADAM J RUSS
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Credential |
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Telephone | 812-479-5208
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 18003640A
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License Number State | IN
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