Provider Demographics
NPI:1710988183
Name:WHITAKER, RUSSELL S (MD)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:S
Last Name:WHITAKER
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 1:300 MEDICAL CENTER DRIVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:GADSDEN
Mailing Address - State:AL
Mailing Address - Zip Code:35903
Mailing Address - Country:US
Mailing Address - Phone:256-492-6982
Mailing Address - Fax:256-494-1958
Practice Address - Street 1:300 MEDICAL CENTER DRIVE
Practice Address - Street 2:SUITE 201
Practice Address - City:GADSDEN
Practice Address - State:AL
Practice Address - Zip Code:35903
Practice Address - Country:US
Practice Address - Phone:256-492-6982
Practice Address - Fax:256-494-1958
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-09
Last Update Date:2009-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL9013207RC0000X
ALMD.9524207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL101301Medicaid
AL51548442OtherBCBS OF AL
AL51548442OtherBCBS OF AL
AL101301Medicaid