=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497724223
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JAMES DAVIS RUSSELL MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/15/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1521 N 10TH ST STE C
-----------------------------------------------------
City | BLYTHEVILLE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72315-1405
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-762-5360
-----------------------------------------------------
Fax | 870-762-1146
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1521 N 10TH ST STE C
-----------------------------------------------------
City | BLYTHEVILLE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72315-1405
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-762-5360
-----------------------------------------------------
Fax | 870-762-1146
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number | C4640
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------