=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578019766
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RUSSELL ENGLAND MD PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/29/2016
-----------------------------------------------------
Last Update Date | 08/31/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2709 W BRIGGS AVE STE. 4
-----------------------------------------------------
City | FAIRFIELD
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 52556-2649
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 641-472-7216
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2709 W BRIGGS AVE STE. 4
-----------------------------------------------------
City | FAIRFIELD
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 52556-2649
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 641-472-7216
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PHYSICIAN
-----------------------------------------------------
Name | RUSSELL D ENGLAND
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 641-472-7216
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | MD23126
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------