Provider Demographics
NPI:1710935663
Name:RUSSELL, ROBERT BURKE (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:BURKE
Last Name:RUSSELL
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:PO BOX 689022
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:TN
Mailing Address - Zip Code:37068-9022
Mailing Address - Country:US
Mailing Address - Phone:615-778-8468
Mailing Address - Fax:615-778-8468
Practice Address - Street 1:29 L V STABLER DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:AL
Practice Address - Zip Code:36037-3850
Practice Address - Country:US
Practice Address - Phone:251-968-7474
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-04
Last Update Date:2017-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL00004219207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL051556309Medicaid
AL051556309Medicaid
ALC70373Medicare UPIN