Provider Demographics
NPI:1114277993
Name:RUSSELL B ALLISON MD PA
Entity Type:Organization
Organization Name:RUSSELL B ALLISON MD PA
Other - Org Name:POTTSVILLE PRIMARY CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:NURSE PRACITIONER
Authorized Official - Prefix:
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:
Authorized Official - Last Name:TOWNSEND
Authorized Official - Suffix:
Authorized Official - Credentials:NPA
Authorized Official - Phone:479-880-1118
Mailing Address - Street 1:PO BOX 1146
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72811-1146
Mailing Address - Country:US
Mailing Address - Phone:479-890-9292
Mailing Address - Fax:479-890-6962
Practice Address - Street 1:5395 W ASH ST
Practice Address - Street 2:
Practice Address - City:POTTSVILLE
Practice Address - State:AR
Practice Address - Zip Code:72858-9170
Practice Address - Country:US
Practice Address - Phone:479-880-1118
Practice Address - Fax:479-880-1120
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-19
Last Update Date:2015-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QR1300X
ARA01298 ANP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR=========OtherTAX ID