Provider Demographics
NPI:1912426123
Name:RUSSELL, MICHAEL L
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:L
Last Name:RUSSELL
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 1:5138 SILENT VALLEY AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89139-7055
Mailing Address - Country:US
Mailing Address - Phone:702-273-8625
Mailing Address - Fax:702-485-1210
Practice Address - Street 1:3852 PALOS VERDES ST
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89119-6909
Practice Address - Country:US
Practice Address - Phone:702-273-8625
Practice Address - Fax:702-273-8625
Is Sole Proprietor?:No
Enumeration Date:2017-09-19
Last Update Date:2017-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator