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General NPI Number Information
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NPI Number | 1245220912
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Entity Type | Individual
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Provider Name | CHARLES E RUSSELL MD
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Gender | Male
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Dates
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Enumeration Date | 10/25/2005
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Last Update Date | 07/23/2024
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Provider Practice Location Address
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Address Line | 415 S MAIN ST
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City | WAYNESVILLE
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State | OH
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Zip | 45068-9553
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Country | US
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Telephone | 513-897-7162
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Fax |
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Provider Business Mailing Address
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Address Line | 3195 DAYTON XENIA RD # 900-162
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City | BEAVERCREEK
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State | OH
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Zip | 45434-6390
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Country | US
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Telephone | 937-718-7677
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Fax | 937-429-7441
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2083A0300X
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Taxonomy Name | Addiction Medicine (Preventive Medicine) Physician
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License Number | 35050063
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License Number State | OH
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