Provider Demographics
NPI:1558759480
Name:RUSSELL, KEVIN D SR
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:D
Last Name:RUSSELL
Suffix:SR
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 1:1351 GATES RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MS
Mailing Address - Zip Code:39429-8948
Mailing Address - Country:US
Mailing Address - Phone:601-441-2515
Mailing Address - Fax:601-736-3872
Practice Address - Street 1:1351 GATES RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MS
Practice Address - Zip Code:39429-8948
Practice Address - Country:US
Practice Address - Phone:601-441-2515
Practice Address - Fax:601-736-3872
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-30
Last Update Date:2014-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172A00000X
MS8878172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver