Provider Demographics
NPI:1013285071
Name:PHILLIPS, RUSSELL GLENN (HEARING SPECIALIST)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:GLENN
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:HEARING SPECIALIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 C. MICHAEL DAVENPORT BLVD.
Mailing Address - Street 2:SUITE 2
Mailing Address - City:FRANKFORT
Mailing Address - State:KY
Mailing Address - Zip Code:40601
Mailing Address - Country:US
Mailing Address - Phone:502-352-2468
Mailing Address - Fax:502-352-2472
Practice Address - Street 1:103 C. MICHAEL DAVENPORT BLVD.
Practice Address - Street 2:SUITE 2
Practice Address - City:FRANKFORT
Practice Address - State:KY
Practice Address - Zip Code:40601
Practice Address - Country:US
Practice Address - Phone:502-352-2468
Practice Address - Fax:502-352-2472
Is Sole Proprietor?:No
Enumeration Date:2011-12-06
Last Update Date:2011-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY0955237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist