Provider Demographics
NPI:1144213240
Name:RUSSELL, RICHARD B (DO)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:B
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 N TULPEHOCKEN ST
Mailing Address - Street 2:
Mailing Address - City:PINE GROVE
Mailing Address - State:PA
Mailing Address - Zip Code:17963-1217
Mailing Address - Country:US
Mailing Address - Phone:570-345-2345
Mailing Address - Fax:570-345-2350
Practice Address - Street 1:121 N TULPEHOCKEN ST
Practice Address - Street 2:
Practice Address - City:PINE GROVE
Practice Address - State:PA
Practice Address - Zip Code:17963-1217
Practice Address - Country:US
Practice Address - Phone:570-345-2345
Practice Address - Fax:570-345-2350
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2007-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS004201L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0007538350005Medicaid
PA0007538350005Medicaid
PA099079Medicare PIN