Provider Demographics
NPI:1396835641
Name:ROBERT C RUSSELL M D S C
Entity Type:Organization
Organization Name:ROBERT C RUSSELL M D S C
Other - Org Name:ROBERT C RUSSELL M D S C
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNERPRESIDEN
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:C
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:217-523-0808
Mailing Address - Street 1:320 E CARPENTER ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62702-5185
Mailing Address - Country:US
Mailing Address - Phone:217-523-0808
Mailing Address - Fax:217-753-5324
Practice Address - Street 1:320 E CARPENTER ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-5185
Practice Address - Country:US
Practice Address - Phone:217-523-0808
Practice Address - Fax:217-753-5324
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-14
Last Update Date:2013-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036061657208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036061657Medicaid
IL036061657Medicaid
IL212105Medicare PIN