MEDICARE: DR. GEORGE V RUSSELL JR. 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	207XX0801X	Orthopaedic Trauma Physician	16970	MS

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	512G700003	OTHER	MS	MEDICARE UP
4	P00628048	OTHER	MS	RAILROAD MEDICARE PTAN#

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	512I200009	OTHER	MS	PTAN UP
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1629072509
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GEORGE V RUSSELL JR. M.D.

Provider Business Mailing Address
First Line	:	2500 N STATE ST
Second Line	:
City	:	JACKSON
State	:	MS
Zip	:	39216-4500
Country	:	US
Telephone Number	:	601-815-1277
Fax Number	:	601-815-1722

Provider Business Practice Location Address
First Line	:	2500 N STATE ST
Second Line	:
City	:	JACKSON
State	:	MS
Zip	:	39216-4500
Country	:	US
Telephone Number	:	601-815-1277
Fax Number	:	601-815-1722

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

Provider Enumeration Date	:	06/09/2005
Last Update Date	:	01/25/2024

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Directions to “ DR. GEORGE V RUSSELL JR. M.D.” Practice Location

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