Provider Demographics
NPI:1477729507
Name:RUSSELL, PATRICIA LYNN (MD)
Entity Type:Individual
Prefix:DR
First Name:PATRICIA
Middle Name:LYNN
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:420 WILLIAM ST
Mailing Address - Street 2:SUITE 1001
Mailing Address - City:RIVER FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60305-1920
Mailing Address - Country:US
Mailing Address - Phone:708-763-2200
Mailing Address - Fax:708-763-4320
Practice Address - Street 1:420 WILLIAM ST
Practice Address - Street 2:SUITE 1001
Practice Address - City:RIVER FOREST
Practice Address - State:IL
Practice Address - Zip Code:60305-1920
Practice Address - Country:US
Practice Address - Phone:708-763-2200
Practice Address - Fax:708-763-4320
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-08
Last Update Date:2012-01-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036-081644207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILE76351Medicare UPIN