Provider Demographics
NPI:1588668529
Name:RUSSELL, ROGER BIVINS (MD)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:BIVINS
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 1:3633 HARDEN RD
Mailing Address - Street 2:STE 200
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27607-3369
Mailing Address - Country:US
Mailing Address - Phone:919-785-0505
Mailing Address - Fax:919-785-0205
Practice Address - Street 1:3633 HARDEN RD
Practice Address - Street 2:STE 200
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607-3369
Practice Address - Country:US
Practice Address - Phone:919-785-0505
Practice Address - Fax:919-785-0205
Is Sole Proprietor?:No
Enumeration Date:2005-06-08
Last Update Date:2010-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC275152086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC74061OtherBCBS
NC8974061Medicaid
NCC86254Medicare UPIN
NC74061OtherBCBS