Provider Demographics
NPI:1245220912
Name:RUSSELL, CHARLES E (MD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:E
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 1:3195 DAYTON XENIA RD # 900-162
Mailing Address - Street 2:
Mailing Address - City:BEAVERCREEK
Mailing Address - State:OH
Mailing Address - Zip Code:45434-6390
Mailing Address - Country:US
Mailing Address - Phone:937-718-7677
Mailing Address - Fax:937-429-7441
Practice Address - Street 1:415 S MAIN ST
Practice Address - Street 2:
Practice Address - City:WAYNESVILLE
Practice Address - State:OH
Practice Address - Zip Code:45068-9553
Practice Address - Country:US
Practice Address - Phone:513-897-7162
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-25
Last Update Date:2024-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH350500632083A0300X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083A0300XAllopathic & Osteopathic PhysiciansPreventive MedicineAddiction Medicine
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000546225OtherANTHEM
OH0573348Medicaid
OH0573348Medicaid
OHRU4205005Medicare PIN
OH0715313Medicare ID - Type Unspecified