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General NPI Number Information
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NPI Number | 1528151610
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Entity Type | Individual
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Provider Name | ROBERT L RUSSELL MD
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Gender | Male
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Dates
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Enumeration Date | 10/02/2006
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Last Update Date | 02/06/2017
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Provider Practice Location Address
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Address Line | 305 HIGHWAY 51
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City | RIDGELAND
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State | MS
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Zip | 39157-3428
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Country | US
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Telephone | 601-856-9980
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Fax | 601-856-9994
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Provider Business Mailing Address
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Address Line | 5606 OLD CANTON RD
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City | JACKSON
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State | MS
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Zip | 39211-4217
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Country | US
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Telephone | 601-856-9980
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Fax | 601-856-9994
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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 | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 12039
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License Number State | MS
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