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General NPI Number Information
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NPI Number | 1356077911
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Entity Type | Individual
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Provider Name | JOSEPH DONALD RUSSOM
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Gender | Male
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Dates
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Enumeration Date | 07/26/2022
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Last Update Date | 07/26/2022
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Provider Practice Location Address
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Address Line | 1221 SHONAT ST
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City | MUSKEGON
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State | MI
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Zip | 49442-5363
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Country | US
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Telephone | 231-666-4443
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Fax |
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Provider Business Mailing Address
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Address Line | 1215 FULTON ST E
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City | GRAND RAPIDS
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State | MI
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Zip | 49503-3849
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Country | US
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Telephone | 616-742-0351
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Fax |
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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 | 175T00000X
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Taxonomy Name | Peer Specialist
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License Number |
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License Number State |
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