MEDICARE: MR. KEON J RUSSELL MS.ED

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	174400000X	Specialist

General Provider Information

NPI Number	:	1538420633
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. KEON J RUSSELL MS.ED

Provider Business Mailing Address
First Line	:	1089 E 72ND ST
Second Line	:	4
City	:	BROOKLYN
State	:	NY
Zip	:	11234-5326
Country	:	US
Telephone Number	:	917-642-0472
Fax Number	:

Provider Business Practice Location Address
First Line	:	1089 E 72ND ST
Second Line	:	4
City	:	BROOKLYN
State	:	NY
Zip	:	11234-5326
Country	:	US
Telephone Number	:	917-642-0472
Fax Number	:

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

Provider Enumeration Date	:	06/05/2012
Last Update Date	:	06/05/2012

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