Provider Demographics
NPI:1326335886
Name:RUSSELL, KEITH PERRY (MD)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:PERRY
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:PO BOX 4767
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39296-4767
Mailing Address - Country:US
Mailing Address - Phone:800-889-8610
Mailing Address - Fax:601-982-7909
Practice Address - Street 1:200 STATE HIGHWAY 30 W
Practice Address - Street 2:
Practice Address - City:NEW ALBANY
Practice Address - State:MS
Practice Address - Zip Code:38652-3112
Practice Address - Country:US
Practice Address - Phone:800-889-8610
Practice Address - Fax:601-982-7909
Is Sole Proprietor?:No
Enumeration Date:2011-07-06
Last Update Date:2023-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MST-24832085R0202X
MS248182085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology