Provider Demographics
NPI:1841219789
Name:KELLY, RUSSELL F (MD)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:F
Last Name:KELLY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:126 MEDICAL DR
Mailing Address - Street 2:
Mailing Address - City:PALESTINE
Mailing Address - State:TX
Mailing Address - Zip Code:75801-8506
Mailing Address - Country:US
Mailing Address - Phone:903-731-0509
Mailing Address - Fax:903-723-3064
Practice Address - Street 1:6701 AIRPORT BLVD STE C138
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36608-3784
Practice Address - Country:US
Practice Address - Phone:251-333-3333
Practice Address - Fax:251-410-4444
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2019-04-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036-082186207RC0000X
TXR1973207RC0000X
AL36353207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILG07451Medicare UPIN