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General NPI Number Information
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NPI Number | 1316092182
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Entity Type | Organization
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Legal Business Name | RENEE J RUSSELL MD INC
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Dates
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Enumeration Date | 01/24/2007
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Last Update Date | 11/11/2016
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Provider Practice Location Address
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Address Line | 900 E 13TH ST SUITE 104
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City | GROVE
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State | OK
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Zip | 74344-2975
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Country | US
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Telephone | 918-786-3100
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Fax | 918-786-3108
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Provider Business Mailing Address
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Address Line | 1110 NEO LOOP
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City | GROVE
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State | OK
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Zip | 74344-6046
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Country | US
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Telephone | 918-786-3100
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Fax | 918-786-3108
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Authorized Official
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Title or Position | PROVIDER
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Name | DR. RENEE JEAN RUSSELL
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Credential | M.D.
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Telephone | 918-786-3100
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 22021
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License Number State | OK
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