Provider Demographics
NPI:1184732067
Name:SOUTH RUSSELL FAMILY PRACTICE, INC.
Entity type:Organization
Organization Name:SOUTH RUSSELL FAMILY PRACTICE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:N
Authorized Official - Last Name:ROOD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:440-338-3366
Mailing Address - Street 1:5192 CHILLICOTHE RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:CHAGRIN FALLS
Mailing Address - State:OH
Mailing Address - Zip Code:44022-4196
Mailing Address - Country:US
Mailing Address - Phone:440-338-3366
Mailing Address - Fax:440-338-3332
Practice Address - Street 1:5192 CHILLICOTHE RD
Practice Address - Street 2:SUITE 101
Practice Address - City:CHAGRIN FALLS
Practice Address - State:OH
Practice Address - Zip Code:44022-4196
Practice Address - Country:US
Practice Address - Phone:440-338-3366
Practice Address - Fax:440-338-3332
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0591515Medicaid
OHSO9288511Medicare ID - Type Unspecified