Provider Demographics
NPI:1578786950
Name:JAMES RUSSELL, M.D, INC.
Entity Type:Organization
Organization Name:JAMES RUSSELL, M.D, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:918-224-3081
Mailing Address - Street 1:308 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SAPULPA
Mailing Address - State:OK
Mailing Address - Zip Code:74066-4110
Mailing Address - Country:US
Mailing Address - Phone:918-224-3081
Mailing Address - Fax:918-224-5059
Practice Address - Street 1:308 S MAIN ST
Practice Address - Street 2:
Practice Address - City:SAPULPA
Practice Address - State:OK
Practice Address - Zip Code:74066-4110
Practice Address - Country:US
Practice Address - Phone:918-224-3081
Practice Address - Fax:918-224-5059
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-11
Last Update Date:2010-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK13810207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100134450BOtherSOONERCARE
OK100134450AMedicaid
OK448463764001OtherBCBS
OK100134450BOtherSOONERCARE
OK448463764Medicare ID - Type UnspecifiedMEDICARE