Provider Demographics
NPI:1619912920
Name:HARRELL, RUSSELL L (MD)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:L
Last Name:HARRELL
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 1:222 OAK AVE
Mailing Address - Street 2:
Mailing Address - City:TOMS RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08753-3348
Mailing Address - Country:US
Mailing Address - Phone:732-914-1919
Mailing Address - Fax:732-341-3303
Practice Address - Street 1:222 OAK AVE
Practice Address - Street 2:
Practice Address - City:TOMS RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08753-3348
Practice Address - Country:US
Practice Address - Phone:732-914-1919
Practice Address - Fax:732-341-3303
Is Sole Proprietor?:No
Enumeration Date:2006-06-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA05246400174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ3910903Medicaid
NJ6308084004OtherCIGNA HMO
NJVP037OtherOXFORD
NJ010052464NJ01OtherST BARNABAS HEALTH
NJ0253384000OtherAMERIHEALTH NJ
NJF02903OtherHEALTH NET PHS
NJ157866OtherAMERIHEALTH ADMIN
NJ6308084OtherCIGNA COMED
NJF02903OtherHEALTH NET PHS
NJE13195Medicare UPIN