Provider Demographics
NPI:1093787988
Name:RUSSELL, JR, ALEXANDER BREVARD (MD)
Entity Type:Individual
Prefix:MR
First Name:ALEXANDER
Middle Name:BREVARD
Last Name:RUSSELL, JR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:245 N BINKLEY ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SOLDOTNA
Mailing Address - State:AK
Mailing Address - Zip Code:99669-7500
Mailing Address - Country:US
Mailing Address - Phone:907-714-4112
Mailing Address - Fax:907-262-2821
Practice Address - Street 1:245 N BINKLEY ST
Practice Address - Street 2:SUITE 101
Practice Address - City:SOLDOTNA
Practice Address - State:AK
Practice Address - Zip Code:99669-7500
Practice Address - Country:US
Practice Address - Phone:907-714-4111
Practice Address - Fax:844-912-3953
Is Sole Proprietor?:No
Enumeration Date:2006-02-03
Last Update Date:2020-07-17
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
GA010653208000000X
AK786208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMD0786Medicaid