Provider Demographics
NPI:1609988021
Name:RUSSELL, ROBERT MITCHELL (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:MITCHELL
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 1:711 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02111-1524
Mailing Address - Country:US
Mailing Address - Phone:617-556-3335
Mailing Address - Fax:617-556-3295
Practice Address - Street 1:750 WASHINGTON ST
Practice Address - Street 2:NE MEDICAL CENTER
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02111-1526
Practice Address - Country:US
Practice Address - Phone:617-636-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA47547207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0157503Medicaid
MA0157503Medicaid
MAC46395Medicare UPIN