Provider Demographics
NPI:1962511790
Name:PROCTOR, RUSSELL J (MD)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:J
Last Name:PROCTOR
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 1:1711 N MCKENZIE ST STE 102
Mailing Address - Street 2:
Mailing Address - City:FOLEY
Mailing Address - State:AL
Mailing Address - Zip Code:36535-2282
Mailing Address - Country:US
Mailing Address - Phone:251-952-6653
Mailing Address - Fax:251-952-6651
Practice Address - Street 1:1711 N MCKENZIE ST STE 102
Practice Address - Street 2:
Practice Address - City:FOLEY
Practice Address - State:AL
Practice Address - Zip Code:36535-2282
Practice Address - Country:US
Practice Address - Phone:251-952-6653
Practice Address - Fax:251-952-6651
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2022-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL18875207RP1001X, 207RS0012X, 207RS0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL253180Medicaid
AL253177Medicaid
AL051557066Medicaid
AL253177Medicaid
AL529931840OtherMEDICAID GROUP
AL051558309Medicare PIN
AL051558309Medicare PIN