Provider Demographics
NPI:1669704508
Name:WILLIAM RUSSELL MD PA
Entity type:Organization
Organization Name:WILLIAM RUSSELL MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-723-4380
Mailing Address - Street 1:600 VIRGINIA AVE STE 2
Mailing Address - Street 2:PO BOX 1726
Mailing Address - City:CUMBERLAND
Mailing Address - State:MD
Mailing Address - Zip Code:21502-4551
Mailing Address - Country:US
Mailing Address - Phone:301-723-4380
Mailing Address - Fax:301-723-4812
Practice Address - Street 1:600 VIRGINIA AVE STE 2
Practice Address - Street 2:
Practice Address - City:CUMBERLAND
Practice Address - State:MD
Practice Address - Zip Code:21502-4551
Practice Address - Country:US
Practice Address - Phone:301-723-4380
Practice Address - Fax:301-723-4812
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-03
Last Update Date:2010-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0050636225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1407824956OtherNPI #1
1407824956OtherNPI #1