MEDICARE: MR. ALEXANDER BREVARD RUSSELL, JR MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	010653	GA
2	208000000X	Pediatrics Physician	786	AK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1093787988
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ALEXANDER BREVARD RUSSELL, JR MD

Provider Business Mailing Address
First Line	:	245 N BINKLEY ST
Second Line	:	SUITE 101
City	:	SOLDOTNA
State	:	AK
Zip	:	99669-7500
Country	:	US
Telephone Number	:	907-714-4112
Fax Number	:	907-262-2821

Provider Business Practice Location Address
First Line	:	245 N BINKLEY ST
Second Line	:	SUITE 101
City	:	SOLDOTNA
State	:	AK
Zip	:	99669-7500
Country	:	US
Telephone Number	:	907-714-4111
Fax Number	:	844-912-3953

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/03/2006
Last Update Date	:	07/17/2020

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