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General NPI Number Information
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NPI Number | 1548407513
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Entity Type | Individual
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Provider Name | RUSSELL STEVEN ANDERSON D.O.
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Gender | Male
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Dates
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Enumeration Date | 01/13/2009
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Last Update Date | 08/07/2023
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Provider Practice Location Address
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Address Line | 777 N MAIN ST
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City | TOOELE
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State | UT
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Zip | 84074-1611
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Country | US
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Telephone | 435-843-2364
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Fax | 435-228-0062
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Provider Business Mailing Address
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Address Line | PO BOX 30180
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City | SALT LAKE CITY
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State | UT
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Zip | 84130-0180
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Country | US
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Telephone | 435-743-5591
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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 | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 5148252-8904
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License Number State | UT
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 5148252-1204
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License Number State | UT
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