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General NPI Number Information
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NPI Number | 1386664407
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Entity Type | Individual
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Provider Name | BERTRAM ROYCE RUSSELL JR. MD
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Gender | Male
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Dates
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Enumeration Date | 07/20/2006
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Last Update Date | 12/10/2008
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Provider Practice Location Address
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Address Line | 701 E MARSHALL ST
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City | WEST CHESTER
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State | PA
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Zip | 19380-4412
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Country | US
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Telephone | 610-431-5132
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Fax | 610-363-9892
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Provider Business Mailing Address
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Address Line | 416 YOUNGSFORD LN
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City | GLADWYNE
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State | PA
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Zip | 19035-1609
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Country | US
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Telephone | 610-658-2244
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Fax | 610-658-2403
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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 | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number | MD020168E
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License Number State | PA
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