Provider Demographics
NPI:1619212693
Name:RUSSELL, RUBEN REGINALD III (STNA)
Entity Type:Individual
Prefix:MR
First Name:RUBEN
Middle Name:REGINALD
Last Name:RUSSELL
Suffix:III
Gender:M
Credentials:STNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22091 LIBBY RD APT 101 AA
Mailing Address - Street 2:
Mailing Address - City:BEDFORD HTS.
Mailing Address - State:OH
Mailing Address - Zip Code:44146
Mailing Address - Country:US
Mailing Address - Phone:216-392-3108
Mailing Address - Fax:
Practice Address - Street 1:22091 LIBBY RD APT 101 AA
Practice Address - Street 2:
Practice Address - City:BEDFORD HTS.
Practice Address - State:OH
Practice Address - Zip Code:44146
Practice Address - Country:US
Practice Address - Phone:216-392-3108
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-03
Last Update Date:2012-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOH23128M211246RP1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy