Provider Demographics
NPI:1639134067
Name:RUSSELL DERMATOLOGY OF CONWAY, PLLC
Entity Type:Organization
Organization Name:RUSSELL DERMATOLOGY OF CONWAY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUS/OFFICE MGR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JACKIE
Authorized Official - Middle Name:D
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-328-5050
Mailing Address - Street 1:2425 DAVE WARD DR
Mailing Address - Street 2:SUITE 202
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72034-8686
Mailing Address - Country:US
Mailing Address - Phone:501-328-5050
Mailing Address - Fax:501-328-2131
Practice Address - Street 1:2425 DAVE WARD DR
Practice Address - Street 2:SUITE 202
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72034-8686
Practice Address - Country:US
Practice Address - Phone:501-328-5050
Practice Address - Fax:501-328-2131
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-19
Last Update Date:2010-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE1574207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ140625002Medicaid
AZ140625002Medicaid