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General NPI Number Information
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NPI Number | 1902120819
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Entity Type | Individual
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Provider Name | ANDREW COLIN RUSSELL MD
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Gender | Male
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Dates
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Enumeration Date | 03/22/2010
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Last Update Date | 10/18/2024
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Provider Practice Location Address
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Address Line | 28 COUNTRY CLUB VW
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City | EDWARDSVILLE
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State | IL
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Zip | 62025-3626
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Country | US
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Telephone | 573-424-9110
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Fax |
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Provider Business Mailing Address
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Address Line | 6800 ILLINOIS 162
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City | MARYVILLE
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State | IL
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Zip | 62062
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Country | US
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Telephone | 618-288-5711
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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 | 207P00000X
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Taxonomy Name | Emergency Medicine Physician
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License Number | 2012023819
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License Number State | MO
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Taxonomy #2
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Taxonomy Code | 207P00000X
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Taxonomy Name | Emergency Medicine Physician
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License Number | 036.134694
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License Number State | IL
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