=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689933152
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANDREW W RUSSELL HIS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/03/2012
-----------------------------------------------------
Last Update Date | 05/03/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 224 MAIN ST
-----------------------------------------------------
City | SALEM
-----------------------------------------------------
State | NH
-----------------------------------------------------
Zip | 03079-3188
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 603-893-2361
-----------------------------------------------------
Fax | 603-893-2780
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 224 MAIN ST
-----------------------------------------------------
City | SALEM
-----------------------------------------------------
State | NH
-----------------------------------------------------
Zip | 03079-3188
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 603-893-2361
-----------------------------------------------------
Fax | 603-893-2780
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 237700000X
-----------------------------------------------------
Taxonomy Name | Hearing Instrument Specialist
-----------------------------------------------------
License Number | H597
-----------------------------------------------------
License Number State | NH
-----------------------------------------------------