Provider Demographics
NPI:1073625794
Name:RUSSELL, PHILIP CHRISTIAN (MD)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:CHRISTIAN
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 JUNE ST
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:ME
Mailing Address - Zip Code:04073-2621
Mailing Address - Country:US
Mailing Address - Phone:401-490-7004
Mailing Address - Fax:
Practice Address - Street 1:25 JUNE ST
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:ME
Practice Address - Zip Code:04073-2621
Practice Address - Country:US
Practice Address - Phone:401-497-1280
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD117242084P0800X
MEMD267402084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry