=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699067074
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ASSOCIATED OWENSBORO UROLOGY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/04/2011
-----------------------------------------------------
Last Update Date | 05/04/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2211 MAYFAIR DR SUITE 401
-----------------------------------------------------
City | OWENSBORO
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42301-4568
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-926-0034
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2211 MAYFAIR DR SUITE 401
-----------------------------------------------------
City | OWENSBORO
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42301-4568
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-926-0034
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PARTNER
-----------------------------------------------------
Name | DR. DAVID P RUSSELL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 270-926-0034
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208800000X
-----------------------------------------------------
Taxonomy Name | Urology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------