Provider Demographics
NPI:1386859148
Name:RUSSELL, SHERILYN JOSEPHINE (MD)
Entity Type:Individual
Prefix:
First Name:SHERILYN
Middle Name:JOSEPHINE
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:22201 MOROSS RD
Mailing Address - Street 2:SUITE 252
Mailing Address - City:GROSSE POINTE
Mailing Address - State:MI
Mailing Address - Zip Code:48236-2169
Mailing Address - Country:US
Mailing Address - Phone:313-343-4411
Mailing Address - Fax:313-343-4412
Practice Address - Street 1:22201 MOROSS RD
Practice Address - Street 2:SUITE 252
Practice Address - City:GROSSE POINTE
Practice Address - State:MI
Practice Address - Zip Code:48236-2169
Practice Address - Country:US
Practice Address - Phone:313-343-4411
Practice Address - Fax:313-343-4412
Is Sole Proprietor?:No
Enumeration Date:2007-05-14
Last Update Date:2012-12-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301084057207RE0101X, 207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIM74460264Medicare PIN