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General NPI Number Information
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NPI Number | 1922451616
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Entity Type | Individual
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Provider Name | DONALD E. RUSSELL IV MS, LAT, ATC
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Gender | Male
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Dates
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Enumeration Date | 07/18/2016
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Last Update Date | 02/29/2020
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Provider Practice Location Address
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Address Line | 650 S BALTIMORE ST
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City | DILLSBURG
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State | PA
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Zip | 17019-9636
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Country | US
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Telephone | 717-432-8691
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Fax | 717-432-7393
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Provider Business Mailing Address
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Address Line | 226 TALL OAK DR
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City | NEW CUMBERLAND
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State | PA
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Zip | 17070-2347
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Country | US
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Telephone | 207-290-1190
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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 | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | RT005841
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License Number State | PA
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