Provider Demographics
NPI:1891772513
Name:RUSSELL, LARRY JOE (MD)
Entity Type:Individual
Prefix:MR
First Name:LARRY
Middle Name:JOE
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 2618
Mailing Address - Street 2:
Mailing Address - City:HENDERSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28793-2618
Mailing Address - Country:US
Mailing Address - Phone:828-693-4431
Mailing Address - Fax:828-693-4434
Practice Address - Street 1:510 BALSAM RD
Practice Address - Street 2:
Practice Address - City:HENDERSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28792-5703
Practice Address - Country:US
Practice Address - Phone:828-693-4431
Practice Address - Fax:828-693-4434
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-22
Last Update Date:2019-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9901016207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
012U9OtherBCBS NC
1232QOtherBCBS NC
N01016OtherSC MEDICAID
80191107OtherRR MEDICARE
611186890OtherFIRST HEALTH
611186890OtherHEALTHCARE SAVINGS
611186890OtherHUMANA TRICARE
A0317OtherMEDCOST
1232QOtherBCBS NC
354567600OtherOWCP
B6811OtherMEDCOST
0102277OtherUNITED HEALTHCARE
030455058OtherCRESENT
0171701OtherUNITED HEALTHCARE
030455058OtherHEALTHCARE SAVINGS
611186890OtherBEECH STREET
N01016OtherSC MEDICAID
030455058OtherCIGNA HEALTHCARE