Provider Demographics
NPI:1992770515
Name:RUSSELL, GREGORY A (MD)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:A
Last Name:RUSSELL
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:PO BOX 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12925 HIGHWAY 601
Practice Address - Street 2:STE 300
Practice Address - City:MIDLAND
Practice Address - State:NC
Practice Address - Zip Code:28107-9535
Practice Address - Country:US
Practice Address - Phone:704-888-3702
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2024-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2010-01130207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1992770515Medicaid
NC5915758Medicaid
NC1598XOtherBCBS
NCNCL516AMedicare PIN
NC1598XOtherBCBS