Provider Demographics
NPI:1558454801
Name:RUSSELL, MICHAEL L (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:L
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 1:1222 S ORANGE AVE
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-1215
Mailing Address - Country:US
Mailing Address - Phone:321-841-7856
Mailing Address - Fax:321-843-6432
Practice Address - Street 1:1222 S ORANGE AVE
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-1215
Practice Address - Country:US
Practice Address - Phone:321-841-7856
Practice Address - Fax:321-843-6432
Is Sole Proprietor?:No
Enumeration Date:2006-10-01
Last Update Date:2016-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC39076207R00000X, 207RC0200X, 207RP1001X
FLME114533207RP1001X, 207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL008144900Medicaid
FLME114533OtherMEDICAL LICENSE
FLME114533OtherMEDICAL LICENSE