Provider Demographics
NPI:1124007950
Name:RUSSELL, KAMAL B (MD)
Entity Type:Individual
Prefix:DR
First Name:KAMAL
Middle Name:B
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 1:39 SLEEPY HOLLOW DR
Mailing Address - Street 2:
Mailing Address - City:NEWTOWN SQUARE
Mailing Address - State:PA
Mailing Address - Zip Code:19073-3929
Mailing Address - Country:US
Mailing Address - Phone:610-359-9191
Mailing Address - Fax:610-359-9292
Practice Address - Street 1:39 SLEEPY HOLLOW DR
Practice Address - Street 2:
Practice Address - City:NEWTOWN SQUARE
Practice Address - State:PA
Practice Address - Zip Code:19073
Practice Address - Country:US
Practice Address - Phone:610-359-9191
Practice Address - Fax:610-359-9292
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-11
Last Update Date:2018-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD025132E2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA099357302Medicaid
PARU165134Medicare ID - Type Unspecified