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General NPI Number Information
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NPI Number | 1689120263
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Entity Type | Organization
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Legal Business Name | RUSSELL MEDICAL SERVICES PLLC
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Dates
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Enumeration Date | 09/01/2016
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Last Update Date | 09/01/2016
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Provider Practice Location Address
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Address Line | 5071 HIGHWAY 82 E
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City | LAKE VILLAGE
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State | AR
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Zip | 71653
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Country | US
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Telephone | 870-515-1289
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Fax |
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Provider Business Mailing Address
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Address Line | 5071 HIGHWAY 82 E
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City | LAKE VILLAGE
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State | AR
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Zip | 71653
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Country | US
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Telephone | 870-515-1289
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Fax |
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Authorized Official
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Title or Position | CHIEF EXECUTIVE OFFICER
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Name | JOHN RANDALL RUSSELL
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Credential | M.D.
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Telephone | 870-515-1289
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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 | C4971
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License Number State | AS
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