MEDICARE: COREY B RUSSELL DPM

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	213E00000X	Podiatrist	36002914	OH

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	:	1467418418
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	COREY B RUSSELL DPM

Provider Business Mailing Address
First Line	:	3055 W SYLVANIA AVE
Second Line	:
City	:	TOLEDO
State	:	OH
Zip	:	43613-4135
Country	:	US
Telephone Number	:	419-473-0125
Fax Number	:	419-473-1230

Provider Business Practice Location Address
First Line	:	3055 W SYLVANIA AVE
Second Line	:
City	:	TOLEDO
State	:	OH
Zip	:	43613-4135
Country	:	US
Telephone Number	:	419-473-0125
Fax Number	:	419-473-1230

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

Provider Enumeration Date	:	04/26/2006
Last Update Date	:	03/21/2016

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Directions to “ COREY B RUSSELL DPM” Practice Location

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