Provider Demographics
NPI:1184627945
Name:RUSSELL, ALLEN J (MD)
Entity Type:Individual
Prefix:
First Name:ALLEN
Middle Name:J
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:6601 COLLEGE BLVD STE 120
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66211-1504
Mailing Address - Country:US
Mailing Address - Phone:913-359-6001
Mailing Address - Fax:217-897-6999
Practice Address - Street 1:32401 8 MILE RD
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48152-1301
Practice Address - Country:US
Practice Address - Phone:913-359-6001
Practice Address - Fax:913-359-5552
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-24
Last Update Date:2023-11-09
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI4301042036208D00000X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4301042036OtherSTATE LICENSE