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General NPI Number Information
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NPI Number | 1780050369
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Entity Type | Individual
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Provider Name | MR. RUSSELL MARCILIS II
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Gender | Male
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Dates
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Enumeration Date | 08/18/2015
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Last Update Date | 01/04/2016
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Provider Practice Location Address
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Address Line | 18121 E. 8 MILE STE 100
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City | EASTPOINTE
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State | MI
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Zip | 48021
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Country | US
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Telephone | 586-585-1446
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Fax |
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Provider Business Mailing Address
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Address Line | 11885 E 12 MILE RD STE 200B
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City | WARREN
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State | MI
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Zip | 48093-3474
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Country | US
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Telephone | 313-799-7935
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 335E00000X
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Taxonomy Name | Prosthetic/Orthotic Supplier
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License Number |
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License Number State | MI
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