Provider Demographics
NPI:1629061189
Name:RUSSELL, JOHN MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:MICHAEL
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:315 PALM COAST PKWY NE
Mailing Address - Street 2:SUITE 3
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32137-3888
Mailing Address - Country:US
Mailing Address - Phone:386-447-4440
Mailing Address - Fax:386-447-4446
Practice Address - Street 1:315 PALM COAST PKWY NE
Practice Address - Street 2:SUITE 3
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32137-3888
Practice Address - Country:US
Practice Address - Phone:386-447-4440
Practice Address - Fax:386-447-4446
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-30
Last Update Date:2007-08-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME57356207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL252330200Medicaid
FL32981XMedicare PIN