Provider Demographics
NPI:1568573947
Name:RUSSELL, BEVERLY (PA)
Entity Type:Individual
Prefix:
First Name:BEVERLY
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 TENEYCK ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-2461
Mailing Address - Country:US
Mailing Address - Phone:517-205-8940
Mailing Address - Fax:517-205-0108
Practice Address - Street 1:1111 TENEYCK ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-2461
Practice Address - Country:US
Practice Address - Phone:517-205-8940
Practice Address - Fax:517-205-0108
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2021-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601004024363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1568573947Medicaid
MI1417961137OtherBCBSM - BMH
MI1417961137OtherBCBSM - BMH
MIC97618326 - BRONSONMedicare PIN