Provider Demographics
NPI:1477282382
Name:RUSSELL, SAMANTHA PAIGE (DO)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:PAIGE
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:169 ASHLEY AVE RM 202
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29425-8905
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10 MCCLELLAN BANKS DR MSC 915
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29425-0001
Practice Address - Country:US
Practice Address - Phone:571-271-6310
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-07
Last Update Date:2022-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCLL87675208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty