Provider Demographics
NPI:1801963376
Name:ANDERSON, RUSSELL
Entity type:Individual
Prefix:
First Name:RUSSELL
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:JOHNSTON CANCER CENTER
Mailing Address - Street 2:514 N BRIGHTLEAF BLVD STE 1100
Mailing Address - City:SMITHFIELD
Mailing Address - State:NC
Mailing Address - Zip Code:27577
Mailing Address - Country:US
Mailing Address - Phone:919-989-2192
Mailing Address - Fax:
Practice Address - Street 1:514 NORTH BRIGHTLEAF BLVD SUITE 1100
Practice Address - Street 2:
Practice Address - City:SMITHFIELD
Practice Address - State:NC
Practice Address - Zip Code:27577
Practice Address - Country:US
Practice Address - Phone:919-989-2192
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2007-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC98-00446207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC891139TMedicaid
NC891139TMedicaid
NC2261188Medicare PIN