Provider Demographics
NPI:1124098728
Name:RUSSELL, JOHN J (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:J
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:1610 N KINGS HIGHWAY ST
Mailing Address - Street 2:SUITE 304
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63701-2196
Mailing Address - Country:US
Mailing Address - Phone:573-335-2191
Mailing Address - Fax:573-335-5524
Practice Address - Street 1:1610 N KINGS HIGHWAY ST
Practice Address - Street 2:SUITE 304
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63701-2196
Practice Address - Country:US
Practice Address - Phone:573-335-2191
Practice Address - Fax:573-335-5524
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-25
Last Update Date:2015-01-21
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MO100521207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO178739OtherHEALTHLINK
MO125591OtherBLUE CROSS BLUE SHIELD
MO203340815Medicaid
MO370018381OtherRAILROAD MEDICARE
MO203340815Medicaid
MO000095083Medicare ID - Type Unspecified