Provider Demographics
NPI:1699723627
Name:RUSSELL, MATTHEW L (MD)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:L
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 CENTRE STREET
Mailing Address - Street 2:DEPARTMENT OF MEDICINE
Mailing Address - City:ROSLINDALE
Mailing Address - State:MA
Mailing Address - Zip Code:02131
Mailing Address - Country:US
Mailing Address - Phone:617-363-8849
Mailing Address - Fax:617-363-8929
Practice Address - Street 1:1200 CENTRE STREET
Practice Address - Street 2:DEPARTMENT OF MEDICINE
Practice Address - City:ROSLINDALE
Practice Address - State:MA
Practice Address - Zip Code:02131
Practice Address - Country:US
Practice Address - Phone:617-363-8849
Practice Address - Fax:617-363-8929
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2015-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA207327207R00000X, 207RG0300X, 207RH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA10033265AMedicaid
MAS400169483OtherMEDICARE PTAN
MAS400169483OtherMEDICARE PTAN