Provider Demographics
NPI:1023097904
Name:CANTRELL, RUSSELL C (MD)
Entity type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:C
Last Name:CANTRELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 843857
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64184-3857
Mailing Address - Country:US
Mailing Address - Phone:314-966-8887
Mailing Address - Fax:314-966-3869
Practice Address - Street 1:1001 S. KIRKWOOD ROAD
Practice Address - Street 2:SUITE 120
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63122-7250
Practice Address - Country:US
Practice Address - Phone:314-966-8887
Practice Address - Fax:314-966-3869
Is Sole Proprietor?:No
Enumeration Date:2006-01-10
Last Update Date:2017-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO103654208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO0425207002OtherCIGNA
MO227927OtherHEALTHLINK
MO4486251OtherAETNA
MO18346OtherBLUE CROSS BLUE SHIELD
MO2300015OtherUNITED HEALTH CARE
MO49861OtherGREAT WEST
MOF57139Medicare UPIN
MO4486251OtherAETNA
MO0425207002OtherCIGNA