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NPI Code Detail

MEDICARE: MR. LARRY JOE RUSSELL MD

MEDICARE: MR. LARRY JOE RUSSELL MD
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
1207Q00000XFamily Medicine Physician9901016NC

Medicare Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
480191107OTHERRR MEDICARE

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1012U9OTHERBCBS NC
21232QOTHERBCBS NC
3MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1891772513
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. LARRY JOE RUSSELL MD
Provider Business Mailing Address
First Line : PO BOX 2618
Second Line :
City : HENDERSONVILLE
State : NC
Zip : 28793-2618
Country : US
Telephone Number : 828-693-4431
Fax Number : 828-693-4434
Provider Business Practice Location Address
First Line : 510 BALSAM RD
Second Line :
City : HENDERSONVILLE
State : NC
Zip : 28792-5703
Country : US
Telephone Number : 828-693-4431
Fax Number : 828-693-4434
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 12/22/2005
Last Update Date : 08/13/2019

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