Provider Demographics
NPI:1710204391
Name:RUSSELL PET M.D. INC
Entity Type:Organization
Organization Name:RUSSELL PET M.D. INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:L
Authorized Official - Middle Name:RUSSELL
Authorized Official - Last Name:PET
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:508-675-0089
Mailing Address - Street 1:4 HARTWELL ST
Mailing Address - Street 2:
Mailing Address - City:FALL RIVER
Mailing Address - State:MA
Mailing Address - Zip Code:02721-3019
Mailing Address - Country:US
Mailing Address - Phone:508-675-0089
Mailing Address - Fax:508-675-2233
Practice Address - Street 1:4 HARTWELL ST
Practice Address - Street 2:
Practice Address - City:FALL RIVER
Practice Address - State:MA
Practice Address - Zip Code:02721-3019
Practice Address - Country:US
Practice Address - Phone:508-675-0089
Practice Address - Fax:508-675-2233
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-22
Last Update Date:2010-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3154564Medicaid
MAG29964Medicare PIN