MEDICARE: DR. LAWRENCE I RUSSELL 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
1	207RC0000X	Cardiovascular Disease Physician	014024	LA

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	:	1407853237
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LAWRENCE I RUSSELL M.D.

Provider Business Mailing Address
First Line	:	4212 WEST CONGRESS STREET
Second Line	:	SUITE 1401
City	:	LAFAYETTE
State	:	LA
Zip	:	70506
Country	:	US
Telephone Number	:	337-981-8131
Fax Number	:	337-989-1316

Provider Business Practice Location Address
First Line	:	4212 WEST CONGRESS STREET
Second Line	:	SUITE 1401
City	:	LAFAYETTE
State	:	LA
Zip	:	70506
Country	:	US
Telephone Number	:	337-981-8131
Fax Number	:	337-989-1316

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

Provider Enumeration Date	:	07/07/2005
Last Update Date	:	03/25/2010

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