Provider Demographics
NPI:1063699783
Name:THE MEDICAL OFFICE OF DR. CAROL M. RUSSELL, P.C.
Entity type:Organization
Organization Name:THE MEDICAL OFFICE OF DR. CAROL M. RUSSELL, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BERT
Authorized Official - Middle Name:
Authorized Official - Last Name:BARRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-727-9544
Mailing Address - Street 1:131 FOREST AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10301-2715
Mailing Address - Country:US
Mailing Address - Phone:718-442-7700
Mailing Address - Fax:718-442-7705
Practice Address - Street 1:131 FOREST AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10301-2715
Practice Address - Country:US
Practice Address - Phone:718-442-7700
Practice Address - Fax:718-442-7705
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-24
Last Update Date:2008-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY238185-1174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
11664647OtherCAQH
1265580096OtherINDIVIDUAL NPI