=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326842303
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SEAN RUSSELL CRNA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/01/2025
-----------------------------------------------------
Last Update Date | 04/01/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 630 EATON AVE
-----------------------------------------------------
City | HAMILTON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45013-2767
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-867-2000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8330 S PORT DR
-----------------------------------------------------
City | WEST CHESTER
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45069-9635
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-218-5574
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 367500000X
-----------------------------------------------------
Taxonomy Name | Certified Registered Nurse Anesthetist
-----------------------------------------------------
License Number | 152466
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------