Provider Demographics
NPI:1366428476
Name:RUSSELL, MICHELLE M (DO)
Entity type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:M
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7700 WASHINGTON VILLAGE DR STE 210
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45459-4094
Mailing Address - Country:US
Mailing Address - Phone:937-562-2291
Mailing Address - Fax:937-562-2293
Practice Address - Street 1:7700 WASHINGTON VILLAGE DR STE 210
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:45459-4094
Practice Address - Country:US
Practice Address - Phone:937-562-2291
Practice Address - Fax:937-562-2293
Is Sole Proprietor?:No
Enumeration Date:2005-12-20
Last Update Date:2020-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34005033207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH590581OtherAETNA
34005033ROtherMEDICAL LICENSE
OH421534506073OtherCARESOURCE
OHD0503304OtherHUMANA/CHOICECARE
OHOC06218OtherNATIONWIDE
OH0887394Medicaid
OH0120237OtherUNITED HEALTH CARE
OH000000227882OtherANTHEM
OH080191704OtherRAILROAD MEDICARE
OH000000227882OtherUNICARE
OH0120237OtherUNITED HEALTH CARE
OH0887394Medicaid