Provider Demographics
NPI:1558341123
Name:RUSSELL, JEREMY PAUL (MD)
Entity Type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:PAUL
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 HAMPTON FALL BLVD
Mailing Address - Street 2:APT. 1111
Mailing Address - City:BROWNSBORO
Mailing Address - State:AL
Mailing Address - Zip Code:35741-8024
Mailing Address - Country:US
Mailing Address - Phone:502-445-6354
Mailing Address - Fax:
Practice Address - Street 1:4210 WHITESPORT CIR
Practice Address - Street 2:# 204
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35801
Practice Address - Country:US
Practice Address - Phone:256-883-8087
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL26988207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine