Provider Demographics
NPI:1952485658
Name:RUSSELL J PROCTOR MD LLC
Entity Type:Organization
Organization Name:RUSSELL J PROCTOR MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:J
Authorized Official - Last Name:PROCTOR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:251-974-1550
Mailing Address - Street 1:PO BOX 7627
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36670-0627
Mailing Address - Country:US
Mailing Address - Phone:251-974-1550
Mailing Address - Fax:251-974-1551
Practice Address - Street 1:4223 ORANGE BEACH BLVD
Practice Address - Street 2:STE. A
Practice Address - City:ORANGE BEACH
Practice Address - State:AL
Practice Address - Zip Code:36561-3459
Practice Address - Country:US
Practice Address - Phone:251-981-8713
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL=========OtherTIN