Provider Demographics
NPI:1356077911
Name:RUSSOM, JOSEPH DONALD
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:DONALD
Last Name:RUSSOM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1215 FULTON ST E
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-3849
Mailing Address - Country:US
Mailing Address - Phone:616-742-0351
Mailing Address - Fax:
Practice Address - Street 1:1221 SHONAT ST
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49442-5363
Practice Address - Country:US
Practice Address - Phone:231-666-4443
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-26
Last Update Date:2022-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist