Provider Demographics
NPI:1245295021
Name:RUSSELL L. PALMER JR, R.T., B.S.
Entity type:Organization
Organization Name:RUSSELL L. PALMER JR, R.T., B.S.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:LEON
Authorized Official - Last Name:PALMER
Authorized Official - Suffix:JR
Authorized Official - Credentials:RT,BS
Authorized Official - Phone:928-777-9064
Mailing Address - Street 1:1045 SCOTT DR
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86301-1731
Mailing Address - Country:US
Mailing Address - Phone:928-777-9064
Mailing Address - Fax:928-777-9183
Practice Address - Street 1:214 WHITE SPAR RD
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86303-4236
Practice Address - Country:US
Practice Address - Phone:928-777-9064
Practice Address - Fax:928-777-9183
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-17
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZCRT-5873335V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335V00000XSuppliersPortable X-ray and/or Other Portable Diagnostic Imaging Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ630001733OtherRAILROAD MEDICARE NUMBER
AZ0722380OtherBLUECROSS/BLUESHIELD I.D.
AZ03-X0009816Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
AZ630001733OtherRAILROAD MEDICARE NUMBER