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General NPI Number Information
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NPI Number | 1194327098
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Entity Type | Organization
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Legal Business Name | PROVIDERGENIX LLC
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Dates
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Enumeration Date | 11/15/2020
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Last Update Date | 11/15/2020
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Provider Practice Location Address
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Address Line | 3100 E 45TH ST STE 234
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City | CLEVELAND
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State | OH
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Zip | 44127-1091
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Country | US
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Telephone | 419-406-0067
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Fax | 866-309-3044
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Provider Business Mailing Address
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Address Line | 3100 E 45TH ST STE 234
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City | CLEVELAND
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State | OH
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Zip | 44127-1091
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Country | US
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Telephone | 419-406-0067
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Fax | 866-309-3044
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Authorized Official
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Title or Position | CEO
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Name | DR. THOMAS LEE RUSSELL
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Credential | DNP, CNP, FNP-C
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Telephone | 419-406-0067
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 163WP0808X
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Taxonomy Name | Psychiatric/Mental Health Registered Nurse
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 163W00000X
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Taxonomy Name | Registered Nurse
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 163WA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Registered Nurse
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 163WG0000X
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Taxonomy Name | General Practice Registered Nurse
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License Number |
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License Number State |
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Taxonomy #6
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Taxonomy Code | 163WH0200X
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Taxonomy Name | Home Health Registered Nurse
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License Number |
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License Number State |
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Taxonomy #7
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Taxonomy Code | 163WI0500X
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Taxonomy Name | Infusion Therapy Registered Nurse
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License Number |
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License Number State |
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Taxonomy #8
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number |
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License Number State |
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Taxonomy #9
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number |
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License Number State |
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Taxonomy #10
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Taxonomy Code | 2084P0802X
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Taxonomy Name | Addiction Psychiatry Physician
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License Number |
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License Number State |
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Taxonomy #11
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number |
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License Number State |
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Taxonomy #12
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number |
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License Number State |
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Taxonomy #13
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Taxonomy Code | 363LP2300X
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Taxonomy Name | Primary Care Nurse Practitioner
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License Number |
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License Number State |
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