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NPI Code Detail

MEDICARE: JOHN CALVIN RUSSELL PA

MEDICARE: JOHN CALVIN RUSSELL PA
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
1363A00000XPhysician Assistant815NE

Other Identifiers

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

General Provider Information

NPI Number : 1275584070
Entity Type Code : Individual
Provider Name (Legal Business Name) : JOHN CALVIN RUSSELL PA
Provider Business Mailing Address
First Line : 2201 N BROADWELL AVE
Second Line :
City : GRAND ISLAND
State : NE
Zip : 68803-2153
Country : US
Telephone Number : 308-382-3660
Fax Number : 308-395-3214
Provider Business Practice Location Address
First Line : 2201 N BROADWELL AVE
Second Line :
City : GRAND ISLAND
State : NE
Zip : 68803-2153
Country : US
Telephone Number : 308-382-3660
Fax Number : 308-395-3214
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/15/2006
Last Update Date : 04/25/2017

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Directions to “ JOHN CALVIN RUSSELL PA” Practice Location

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