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NPI Code Detail

MEDICARE: KENNETH CARL RUSS M.D.

MEDICARE: KENNETH CARL RUSS M.D.
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
1207QA0401XAddiction Medicine (Family Medicine) PhysicianA48224CA

General Provider Information

NPI Number : 1245258235
Entity Type Code : Individual
Provider Name (Legal Business Name) : KENNETH CARL RUSS M.D.
Provider Business Mailing Address
First Line : 36917 COOK ST STE 103
Second Line :
City : PALM DESERT
State : CA
Zip : 92211-6072
Country : US
Telephone Number : 760-835-0425
Fax Number : 760-416-6843
Provider Business Practice Location Address
First Line : 7885 ANNANDALE AVE
Second Line :
City : DESERT HOT SPRINGS
State : CA
Zip : 92240-1419
Country : US
Telephone Number : 760-329-2924
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/17/2006
Last Update Date : 12/15/2025

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