=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124280490
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | WILL THOMAS RUSSELL DO
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/27/2008
-----------------------------------------------------
Last Update Date | 12/17/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 206 E BROWN ST
-----------------------------------------------------
City | EAST STROUDSBURG
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18301-3094
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-476-3353
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2545 SCHOENERSVILLE RD
-----------------------------------------------------
City | BETHLEHEM
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18017-7300
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 484-884-2888
-----------------------------------------------------
Fax | 484-884-2885
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number | OT012329
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number | OS015414
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------