Provider Demographics
NPI:1457508855
Name:RUSSELL, RONALD (QBHP)
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:QBHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:139C E JACKSON AVE
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:AR
Mailing Address - Zip Code:71655-4933
Mailing Address - Country:US
Mailing Address - Phone:501-262-2544
Mailing Address - Fax:870-224-8110
Practice Address - Street 1:139C E JACKSON AVE
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:AR
Practice Address - Zip Code:71655-4933
Practice Address - Country:US
Practice Address - Phone:501-262-2544
Practice Address - Fax:870-224-8110
Is Sole Proprietor?:No
Enumeration Date:2008-08-27
Last Update Date:2019-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator