Provider Demographics
NPI:1013085455
Name:PHILLIPS, RUSSELL E (MD)
Entity type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:E
Last Name:PHILLIPS
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 1:239 VALLEY RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:HAVERFORD
Mailing Address - State:PA
Mailing Address - Zip Code:19041-2028
Mailing Address - Country:US
Mailing Address - Phone:610-896-5710
Mailing Address - Fax:610-896-1667
Practice Address - Street 1:239 VALLEY RIDGE RD
Practice Address - Street 2:
Practice Address - City:HAVERFORD
Practice Address - State:PA
Practice Address - Zip Code:19041-2028
Practice Address - Country:US
Practice Address - Phone:610-896-5710
Practice Address - Fax:610-896-1667
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-02
Last Update Date:2022-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD015455E2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
125370300OtherDEPT OF LABOR, OWCP
PAPH126779OtherHIGHMARK BLUE SHIELD
PA0056423000OtherINDEPENDENCE BLUE CROSS
125370300OtherDEPT OF LABOR, OWCP
PH126779Medicare ID - Type Unspecified