Provider Demographics
NPI:1609879253
Name:RUSSELL, DALLAS M (MD)
Entity Type:Individual
Prefix:DR
First Name:DALLAS
Middle Name:M
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 1:790 MONTCLAIR RD
Mailing Address - Street 2:STE 210
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35213-1966
Mailing Address - Country:US
Mailing Address - Phone:205-595-3600
Mailing Address - Fax:205-595-3663
Practice Address - Street 1:790 MONTCLAIR RD
Practice Address - Street 2:STE 210
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35213-1966
Practice Address - Country:US
Practice Address - Phone:205-595-3600
Practice Address - Fax:205-595-3663
Is Sole Proprietor?:No
Enumeration Date:2005-05-27
Last Update Date:2008-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL12098174400000X, 2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL5290002380Medicaid
AL82356Medicare PIN
AL51082356Medicare PIN
ALC74517Medicare UPIN
AL5290002380Medicaid