Provider Demographics
NPI:1811020225
Name:JOHN J. RUSSELL, MD, PC
Entity Type:Organization
Organization Name:JOHN J. RUSSELL, MD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:J
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:573-335-4209
Mailing Address - Street 1:1435 N MOUNT AUBURN RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63701-2171
Mailing Address - Country:US
Mailing Address - Phone:573-335-4209
Mailing Address - Fax:573-335-5524
Practice Address - Street 1:1435 N MOUNT AUBURN RD
Practice Address - Street 2:SUITE 200
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63701-2171
Practice Address - Country:US
Practice Address - Phone:573-335-4209
Practice Address - Fax:573-335-5524
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO100521207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Not Answered208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOF26007Medicare UPIN