Provider Demographics
NPI:1063486660
Name:RUSSELL, JOHN R (DO)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:R
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:DO
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Mailing Address - Street 1:2700 CLAY EDWARDS DR
Mailing Address - Street 2:SUITE 240
Mailing Address - City:NORTH KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64116-3251
Mailing Address - Country:US
Mailing Address - Phone:816-691-5287
Mailing Address - Fax:816-346-7690
Practice Address - Street 1:6080 N OAK TRFY
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64118-5158
Practice Address - Country:US
Practice Address - Phone:816-453-9232
Practice Address - Fax:816-455-2423
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-13
Last Update Date:2016-02-11
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Provider Licenses
StateLicense IDTaxonomies
MO36959207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1063486660Medicaid
MO243649753Medicaid
MO0004272Medicare PIN
MO1063486660Medicaid
MOE84596Medicare UPIN