Provider Demographics
NPI:1558592675
Name:RUSSELL, KEVIN LEIGH
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:LEIGH
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:MSRON-6
Mailing Address - Street 2:BLDG 15, NORFOLK NAVAL SHIPYARD
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23709
Mailing Address - Country:US
Mailing Address - Phone:757-967-4177
Mailing Address - Fax:
Practice Address - Street 1:MSRON-6
Practice Address - Street 2:BLDG 15, NORFOLK NAVAL SHIPYARD
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23709
Practice Address - Country:US
Practice Address - Phone:757-967-4177
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-06
Last Update Date:2009-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman