MEDICARE: RUSSELL MEDICAL CLINIC

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	207Q00000X	Family Medicine Physician	208D00000X	MS

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	C02872	OTHER	MS	MEDICARE GROUP

Other Identifiers

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

General Provider Information

NPI Number	:	1205024452
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RUSSELL MEDICAL CLINIC

Provider Business Mailing Address
First Line	:	402 DOCTORS DR
Second Line	:
City	:	NEW ALBANY
State	:	MS
Zip	:	38652-3109
Country	:	US
Telephone Number	:	662-534-2486
Fax Number	:	662-534-2839

Provider Business Practice Location Address
First Line	:	402 DOCTORS DR
Second Line	:
City	:	NEW ALBANY
State	:	MS
Zip	:	38652-3109
Country	:	US
Telephone Number	:	662-534-2486
Fax Number	:	662-534-2839

Authorized Official
Title or Position	:	OWNER/PHYSICIAN
Name	:	DR. RICHARD H. RUSSELL
Credential	:	M.D.
Telephone Number	:	662-534-2486

Provider Enumeration Date	:	10/11/2007
Last Update Date	:	10/12/2007

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Directions to “RUSSELL MEDICAL CLINIC ” Practice Location

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