Provider Demographics
NPI:1154917375
Name:MICHAEL S RUSSELL, OD, LLC
Entity type:Organization
Organization Name:MICHAEL S RUSSELL, OD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:S
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:630-355-6878
Mailing Address - Street 1:1112 S WASHINGTON ST STE 214
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60540-7964
Mailing Address - Country:US
Mailing Address - Phone:630-355-6878
Mailing Address - Fax:630-355-0043
Practice Address - Street 1:1112 S WASHINGTON ST STE 214
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60540-7964
Practice Address - Country:US
Practice Address - Phone:630-355-6878
Practice Address - Fax:630-355-0043
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-13
Last Update Date:2020-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty