Provider Demographics
NPI:1235145335
Name:STEVENS, RUSSELL WAYNE (MD)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:WAYNE
Last Name:STEVENS
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 1:5320 HIGHWAY 90 W
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36619-4202
Mailing Address - Country:US
Mailing Address - Phone:251-666-8232
Mailing Address - Fax:251-661-1302
Practice Address - Street 1:5100 RANGELINE SERVICE RD N
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36619-9504
Practice Address - Country:US
Practice Address - Phone:251-661-4454
Practice Address - Fax:251-666-3166
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2008-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL00026655207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALG58829Medicare UPIN