Provider Demographics
NPI:1316092182
Name:RENEE J RUSSELL MD INC
Entity type:Organization
Organization Name:RENEE J RUSSELL MD INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:RENEE
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:918-786-3100
Mailing Address - Street 1:1110 NEO LOOP
Mailing Address - Street 2:
Mailing Address - City:GROVE
Mailing Address - State:OK
Mailing Address - Zip Code:74344-6046
Mailing Address - Country:US
Mailing Address - Phone:918-786-3100
Mailing Address - Fax:918-786-3108
Practice Address - Street 1:900 E 13TH ST
Practice Address - Street 2:SUITE 104
Practice Address - City:GROVE
Practice Address - State:OK
Practice Address - Zip Code:74344-2975
Practice Address - Country:US
Practice Address - Phone:918-786-3100
Practice Address - Fax:918-786-3108
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2016-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK22021207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100017290DMedicaid
OK900522115Medicare ID - Type UnspecifiedMEDICARE GROUP #
OKH73424Medicare UPIN
OK249321002Medicare ID - Type UnspecifiedMEDICARE INDIVIDUAL #