Provider Demographics
NPI:1912075631
Name:RUSSELL, KIRK SHANE (MD)
Entity Type:Individual
Prefix:DR
First Name:KIRK
Middle Name:SHANE
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:MD
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Other - Credentials:
Mailing Address - Street 1:3186 VILLAGE DR
Mailing Address - Street 2:SUITE 201
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-3978
Mailing Address - Country:US
Mailing Address - Phone:910-486-5700
Mailing Address - Fax:910-486-5950
Practice Address - Street 1:70 BLUE HERON CT
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:NC
Practice Address - Zip Code:27332-6644
Practice Address - Country:US
Practice Address - Phone:718-807-5166
Practice Address - Fax:718-807-5166
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2023-11-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY2303242085R0202X
NC2014-020642085R0202X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1912075631Medicaid
NC1912075631Medicaid