MEDICARE: RICHARD 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	171M00000X	Case Manager/Care Coordinator

General Provider Information

NPI Number	:	1881371417
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RICHARD RUSSELL

Provider Business Mailing Address
First Line	:	6270 WHITETAIL RUN
Second Line	:
City	:	OAKWOOD
State	:	OH
Zip	:	44146
Country	:	US
Telephone Number	:	216-848-5306
Fax Number	:

Provider Business Practice Location Address
First Line	:	17325 EUCLID AVE STE 3026
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44112-1255
Country	:	US
Telephone Number	:	803-565-9742
Fax Number	:

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

Provider Enumeration Date	:	07/05/2023
Last Update Date	:	07/05/2023

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