Provider Demographics
NPI:1760478242
Name:STAHL, RUSSELL FRANK (MD)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:FRANK
Last Name:STAHL
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 1:920 DOUG WHITE DR STE 510
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29572-4183
Mailing Address - Country:US
Mailing Address - Phone:843-497-7772
Mailing Address - Fax:843-848-7530
Practice Address - Street 1:920 DOUG WHITE DR STE 510
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29572-4183
Practice Address - Country:US
Practice Address - Phone:843-497-7772
Practice Address - Fax:843-848-7530
Is Sole Proprietor?:No
Enumeration Date:2005-09-21
Last Update Date:2022-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC39914174400000X
PAMD-033209E174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0016335280009Medicaid
PA01633528Medicaid
PA402486PU3Medicare ID - Type Unspecified
PA0016335280009Medicaid