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General NPI Number Information
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NPI Number | 1578785911
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Entity Type | Organization
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Legal Business Name | JEREMY P. RUSSELL MD LLC
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Dates
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Enumeration Date | 05/03/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 4810 WHITESPORT CIR SW SUITE 204
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City | HUNTSVILLE
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State | AL
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Zip | 35801-7419
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Country | US
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Telephone | 256-883-8087
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Fax | 256-883-8284
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Provider Business Mailing Address
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Address Line | 4810 WHITESPORT CIR SW SUITE 204
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City | HUNTSVILLE
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State | AL
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Zip | 35801-7419
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Country | US
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Telephone | 256-883-8087
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Fax | 256-883-8284
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Authorized Official
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Title or Position | OWNER
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Name | JEREMY P RUSSELL
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Credential | MD.
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Telephone | 256-883-8087
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 26988
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License Number State | AL
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