MEDICARE: RUSSELL J PROCTOR MD LLC

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	207RP1001X	Pulmonary Disease Physician
2	207R00000X	Internal Medicine Physician

General Provider Information

NPI Number	:	1952485658
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RUSSELL J PROCTOR MD LLC

Provider Business Mailing Address
First Line	:	PO BOX 7627
Second Line	:
City	:	MOBILE
State	:	AL
Zip	:	36670-0627
Country	:	US
Telephone Number	:	251-974-1550
Fax Number	:	251-974-1551

Provider Business Practice Location Address
First Line	:	4223 ORANGE BEACH BLVD
Second Line	:	STE. A
City	:	ORANGE BEACH
State	:	AL
Zip	:	36561-3459
Country	:	US
Telephone Number	:	251-981-8713
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. RUSSELL J PROCTOR
Credential	:	MD
Telephone Number	:	251-974-1550

Provider Enumeration Date	:	10/25/2006
Last Update Date	:	06/21/2018

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