MEDICARE: MRS. ELEANOR M. RUSSELL

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	163WC0200X	Critical Care Medicine Registered Nurse	041.170533	IL
2	363LA2100X	Acute Care Nurse Practitioner	209.005019	IL

General Provider Information

NPI Number	:	1518110725
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. ELEANOR M. RUSSELL

Provider Business Mailing Address
First Line	:	1229 DIANE LN
Second Line	:
City	:	ELK GROVE VILLAGE
State	:	IL
Zip	:	60007-3056
Country	:	US
Telephone Number	:	847-352-9425
Fax Number	:	847-985-0226

Provider Business Practice Location Address
First Line	:	1229 DIANE LN
Second Line	:
City	:	ELK GROVE VILLAGE
State	:	IL
Zip	:	60007-3056
Country	:	US
Telephone Number	:	847-352-9425
Fax Number	:	847-985-0226

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

Provider Enumeration Date	:	10/31/2008
Last Update Date	:	12/31/2021

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